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FeyoUR [g C <br /> STATE OF CALIFORNIA G�9 <br /> { STATE WATER RESOURCES CONTROL BOARD w � o <br /> I� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •C�{.FOMN� <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANEN SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �z <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FBA OR FAG( TY NAME NAME OF OPERATOR <br /> �Qr ©✓1 C1'� e, U ire ei Ci O ir /►'Z f4'7 <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 470 .Al+. M G I.� S C9 r - <br /> CITY NAME STATE ZIP CODE S TE PHONE#WITH AREA CODE <br /> IM r,A CS CA 5 336 '' �3 �3/-H <br /> ✓ BOX CORPORATION INDIVIDUAL PARTNERSHIP OLOCAL-AGENCY I� COUNTY-AGENCY Q STATE-AGENCY —1 FEDERAL-AGENCY <br /> TOINOICATE DISTRICTS <br /> TYPE OF BUSINESSC,pS STATION 2 DISTRIBUTOR I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> D RESERVATON <br /> F-1 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NRJE(LAST,FIRST) P ONE#WITH AREA CODE DAYS: AME(L,AST,FIRS <br /> 4 V C-�mc,n L c{v v-en 2� SSrZ - `l1 e l� c7, .4_ <br /> t L'on nr'� #WIT ODF _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA T,FURS <br /> Tf <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME OARS OF ADDRESS INFORMATION <br /> 'i�e— L � ✓ box bIndicate <br /> MAILIN ORSTREET ADDRESS INDIVIDUAL 0 LOCAL-AGENCY © STATE-AGENCY <br /> -3� (�� r, e FeCORPORATION PARTNERSHIP Q COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAM }� { STAJ,F_ ZIP COD ^_30 <br /> PHONE#WITH AREA CODE <br /> AL TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> CARE OF ADDRESS WFORMATIDN <br /> NAME OFWNER <br /> D e- <br /> MAILING OR STREET ADDRESS <br /> -1—W, l ✓ box m indicate 0 INDIVIDUAL LOCAL-AGENCY FEDERAL-AGENCY <br /> S Z-S �! � T— L�'CURPORATION I] PARTNERSHIP �]COUNTY-AGENCY 0 FEDERAL•AGENCY <br /> r STAT ZIP COD ONE#WITH AREA CODE <br /> CITY NAME <br /> O3i 2.-3(2 P`z CAtj S © Zc-// <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - C5 p b [ 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F,/ baxnlndiaate ED 1 SELF-INSURED 2 GUARANTEE 1 INSURANCE j 1 4 SURETY BOND <br /> C� 5 LETTER OFGTIEDIT Q 6 EXEMPTION 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 /> CHECI(ONE 80X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[:] It.[:j Ill.;�� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLkGANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 'FACILITY# gr'4C C)4`1 <br /> -� a 011 741qul <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISDR-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.FORO <br /> FORM A(5-91) <br /> 0 44� �2 <br />