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65a„�cCS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE rd <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY O SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY a I NAME OF OPERATOR_ <br /> /yT/ _,ad <br /> eA <br /> ADDRESS NEARESTCROSSSTRE PARCEL#(OPTIONAL) <br /> D Nr r T h� <br /> CITU N�AM/EJ ST CA ZI CODE 953� SITE OPHONE?WITH AREA <br /> J --CC <br /> ✓BOX O CORPORATION ®.INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' (] STATE-AGENCY' ED FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'Nuwneruf USTeapubkagwq.o NyleUNeblbwn¢I of supeMmrol dNlsbn,seaion w offin which operates the UST <br /> TYPE OF BUSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓IF INDIAN 1#OFTANKS AT SITE E.P.A. L D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L�sT,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PONE#WITH AREA CU <br /> q�'eC r�rra�i' /L) X36 /!�J `fY NIGHTS: NAME(LAST,RRST)�N/ // PHONE#WITH AAREA COODE�y// NIGH�'NAME(LAS,FIRST) JNPH�%��THAREA C/ h ' /VCTU� 9w �D —bZb7 Y <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box lomizate 2SI INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> g f/ z O CORPORATION 11 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �(. <br /> C/ 3 ;�O � 2 JE z5 <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAMEOF OWNER CARE OF ADDRESS INFORMATION <br /> U <br /> MAILING OR STREET ADDRESS ✓ baslondicateINDIVIDUAL O LOCAL-AGENCY f� STATE-AGENCY <br /> I[o 99 N, Z O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY -7M STATS Zlg 5�3 � PHONOE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBECRR-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ ®- 0 3 7j <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓WXWWCale D 1 SELF-NSURE9 O 2 GUARANTEE ,11 3INSURANCE O 4 SURETYBOND =5 LETTEROFCREDIT Q 6 EXEMPTION O 7 STATE FUND <br /> O B STATE FUND&CHIEF F#UNCIPLOFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT O 19 LOCAL GOVT.MECHANISM 0 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: 1.10 II.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> are l�l+�aut <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> S # FACILITY# <br /> ay /� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,UNLESIS A CHANGrE OF SITt INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNOERGflO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />