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STATE OF CALIFORNIA ��� `�. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e� '° <br /> I , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ' �,�,�e�,,,.' <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT I] 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED S1TE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION d ADDRESS•(MUST BE COMPLETED) <br /> ;ADDRESS <br /> R FACILITY NAME ME OF OPERATOR <br /> r .9ir.�. <br /> TCROSS STREG7 PARCEL 0(OPIONAU <br /> 9 \Cff, ?rMIE STATE2121 SITEPHO EaWITHAREACODE <br /> BoxCA INpCATE C7PORATgN D 1NDIVIDIIAI PARTNFASHIP D LOCA4AGFNCY O CWNIYiU3ENCV' O SPATE-AG — ����er d UST le a Pubic agency,m IW the 1 DISTRICTS' PFIIERLL#GENCY' <br /> rnp following:name A SuPeNMor W olv4bn,section,or office which OWW"the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBDTOfl ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(apf/n-- <br /> 3 FARM 4 PROCESSOR 0 6 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME MST,FIRST) PHONE i WITH AREA CODE JAIS. NAME(UST,FI ST) PHONE#YVITH AREA CODE <br /> a - ILo e I 9 b _ )Dq <br /> 3: NAME(LAS FI ST) PH(o o ATH AREA CODE N TS: NAME(LAS , IRST) PHONE ,WITH AREA CODE <br /> Mci, r' rn 4 - to 3 n 7 ObaS <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME C RE OF ADDRESS INF R"i"N <br /> Q <br /> S <br /> MAILING OR STREET SS ✓ bor bl Cl i- <br /> � INDIVIDUAL Q LOCAL-AGENCY =STATE-AGENCY <br /> 11 T' <br /> CORPORATION O vARTNEnRMP O COUxTY#(ENCV O(X)<�jDE_nv`( <br /> ENOy <br /> ZI � JAECh ST T PHONE a W TH AREA <br /> J12�4 , <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> AME OF OWNER �. OF AD KESS INF TION <br /> YY\ r <br /> MAIL_tSIS.NG OR S1TN,'E�ET AODRE ✓bF b I� INDIVIDUAL =LOCAL-AGENCY =STATE AGENCY <br /> �/�' 7 CORPORATION E::] PARTNERSHIP 0 COUNTYAGENCY = FEDEMLAGENCY <br /> Cfr�NAME PHONE ITH AREA <br /> r 3� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> ---TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓pprb6y"Ni SELF-INSURED L-12 GUARANTEE 0 3 INSURANCE O 4 SURETYIDND <br /> 6 LETTER OF CREDIT i=6 EXEMPTION = N 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: LO it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> 7RS NAME(PRINT 6SIGNED OWNER'S TrTLE PATE -7 MONTIypA9EAR <br /> d 1 - I q5 <br /> LOCAL AGE14CY USE ONLY <br /> COUNTY IF JURISDICTION• FACILITY <br /> LOCATION CODE-OPTIONAL CENSUS TRACT 8 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTONAL - <br /> q <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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOROOJ1ARl <br />