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.• STATE OF CALIFORNIA - ,-•,• °i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ry. , <br /> COMPLETE THIS FORM FOR EAC ITYISRE <br /> MAflK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION I,❑ T PERmomr1;'y'cL'n&'1ojrrE <br /> ONE REM ❑ 2 INTERIM PEPMIT ❑ d AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> NAME LIFO RATOR <br /> 08A OR FACILITY NAMEJ p, o <br /> 7- /e�{� NEARESTC Sl�r` I PMCELAIOPfONAU <br /> ADDRESS ' J <br /> PHONE 8 WITH AREA CO <br /> CITY NAME STATE LP CO E 7 LD / \ <br /> ti«.A QCs ca 53 <br /> ✓ BOX , <br /> TO INDICATE E CWPORMDON Q INDIVIDUAL Q PARTNERSHIP Q W Po-AGENCY � COUNTY-AGENCY CI STATE-AGENCY FFFDERAL�GENCY <br /> DIS <br /> ❑ ✓ 1F INDIAN s OF TANKS AT SITECTS <br /> E.P.A L D.x NWIT W; <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> EDAY,S-./NAMEAST,FIR PHONEAWITH AREACODE DAYS: NAME(LAST.FIRST) <br /> (LYST.FIRST) PHONES WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> vIONEaI HEN <br /> II. PROPERTY OWNER INFORMATION• UST BE COMPLETED CARE OF AD SS I/NFORMATIpl�'().I �a <br /> NAME /� �O�'I� i lJC V '` t <br /> - STATE-AGENCY <br /> MAILING STREET AODR ^ INDNWUAL LOCAL-AGFNCY <br /> Y/' �Gi CORfVRATKIN I� PARTNERSMP CWNfY-AGENCY FEDEML-AGENCY <br /> CITY ME ST ,7 <br /> CORPORATION <br /> C I P WRFt,�A DE` 7L h <br /> L/E U l F7/ C` J 66 L:J LI.Jf V <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS •� A01 blMk]M = INDIVIDUAL = LOCAL-AGENCY = STATEAGENCY <br /> CORPORATION = PARTNERSHIP =COUNN AGENCY = FEDERAL-AGENCY <br /> CITY NAME I STATE I LP CODE PHONE.WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) H074 4 0 ;TC <br /> 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM (S) USED <br /> ✓ OmbFtlka4 Q I SELNNSURED =2 GUARANTEE SINSURANCE O A SURETYBDND <br /> []5 IETTEROFCREDRT u b EXEMPTION 099 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND SILLWG: LU 11. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTEDA SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION a FACILITY z 1,701 V6/f- <br /> 1 <br /> n <br /> LOCATION CODE -OPTAFL ICENSUS TRACT. -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 'G <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SR, IORM ION ONLY. <br /> /(JFORMA(i9/) �/ FORI 7A <br />