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• STATE OF CALIFORNIA • exe u, <br /> of <br /> STATE WATER RESOURCES CONTROL BOARD +m� e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A n , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE In 'e <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> INFORMATIO.N&ADDRESS-M(MUST BE COMPLETED) <br /> DBA / NAME nrO�/L,,,r NAME <br /> OF OPR1R1 Yo <br /> ADDRESS NEAR TCROSS STRE PARCEL#(OPTIONAL) <br /> 33 4 r r-r s �. l <br /> CITU NAME \ CA$TZIPCGOE� a SIT PHO #WITH AREA CODE <br /> y—, q1 5 6 2o-1 599-Z3l 3 <br /> ✓BoX CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #ownarof UST u a Pub&agency,canolete 0e following:rem@OI5upenvorofdM$ion,WionoroKce0hopeMmtho UST <br /> TYPE OF BUSINESS1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAVS�N/♦MSE(LAST,FIRST) 1 11 ' ��� E p WITH ARFA C�OD�jE DAYS:,NAME(LAS�nST) u / l HO�k�TH AREA COD S�/ <br /> NIGHT NTAAMEE(LAST,FIRS t 11, / PHO k Wlp(TH AREAC6ODE NllGji7S: NJ _CA,M.E(LAST,FIRSL~�IFd�✓� a•'•7 PHPE# H AREA RE 3COD62 <br /> If <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) (///�/V <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa to W-10 NDIVIDUAL LOCAL-AGENCY E:3 STATE-AGENCY <br /> ?,C),eO♦ BQ,?,c 1 5•j q INCORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU /4T.a'�� ^ ` STAT, ZIPCODE � ,`z PHONE#WITH AREA CODE <br /> S ,1/JGL"il,✓.G_W—oma C 3 V <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER /� CARE OF ADDRESS INFORM <br /> TION / <br /> r0✓� Pr—o(SLL�. ,' Gr��u/� 6 <br /> MAILOODTETDORVL/ box londicate ' OINDMOUAL = LOCAL-AGENCY =STATE-AGENCY <br /> OE <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PH NE#WI REA CODE <br /> S^ e5,4 S ZS 8 2— OD <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 W- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to intlicate l SELF-INSURED 0 2 GUARANTEE O 3 INSUMNCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> B STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM = 99 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 BILLING: I.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> NA ME(PRINTED&SIGN URE) 7ANKBV%4Ef1'S TITLE DATE NO TWO EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION M FACILITY N <br /> m <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORK THE LOCAL AGENCY IMPLEMENTING THE UNDERGR09STORAGE TANK REGULATIONS <br />