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• M � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :m - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE .a <br /> MARK ONLY —I NEW PERMIT 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 5j <br /> DBA OR FACILITY NAME NAME OF OPERATOR�� � <br /> ADDRESS`'O a3 �� t, _' NEAREST CUiOS�STRFET PARCEL810PTIONAL) <br /> CITY NAME �' STATE SITE SITE PHONEX LTH AREA CODE <br /> /j CA SZ3G 8'8'V,3000 <br /> ✓BOX 0 CORPORATION INDIVIDUAL O PARTNERSHIP D LDCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY' ED FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> It Dwneral UST 6 a pW5c agency,cnniplete the following:name ol supeNwrof division,section oro8ice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR RE EIRVADIAN TON #OF TANK AT SITE E.P.A. <br /> /.PA.A/I.D.X(optional) <br /> Q 3 FARM Q 4 PROCESSOR [j4 5 OTHER OR TRUST LANDS C�T(i 02/L F3, 4!5 Ir <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRSTL� `PHONE M WITH ARE/1 CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHT.T-. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFO) <br /> NAME„-.. , CARE OF ADDRESS INFORMATION <br /> MAILINGORSTRFET:AODRESS _J ✓ kr t0°�1e ByIN'DIVIDUAL O LOCAL-AGENCY O STATE-AGENCY _ <br /> [� CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME ��Ck �,�� S /QE� ZIP DE _� O PHONE 2 WITH AREA COD�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) G 7` f <br /> NAME OF OWNE I� CARE OF ADDRESS INFORMATION <br /> MAWNGOR STREET ADDRESS S ✓ butondicate .®LTLIDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> L Z 4L/a elf R!/1-r— E:]CORPORATION O PARTNERSHIP I=COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME� STaTE,nX ZIP OOE ,t� PHONE pAWI ARE DE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bor to iMirate O 1 BELE-INSURED I= 2 GUARANTEE I=31NSURANCE l=4 SURETY BOND 0 5 LErrEROFCREDIr = 6 EXEMPTION l�7 BTATE FUND -� <br /> O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT =1 to LOCAL GOVT.MECHANISM O 99 OTHER u <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.❑ 11.J�T III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALIY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> t ebj .z <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRA�CTp -9P,TIONAL SUPVISORO•DRICT9 PE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BOY"(AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> - I 1 <br />