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�6pUP �T <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 'C <br /> r, COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ff <br /> MARK ONLY 1 NEYV PERMIT L] 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT [7 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OL-QP TOR <br /> i� � ��'•��P�s «C, <br /> ADDRESS NEAR ST CROSS STREET PARCEL#(OPTIONAL) <br /> /.j�lJ yo SG`-�,a�J/TG �✓y f,f /ll�rvV 24PS-.22.6—6¢^ <br /> clTv NAME ,TSA STATE A ZIP coD�33� Za'F, r�_ AREA j31 <br /> ✓ BOX ORPORATION INDIVIDUAL (_] PARTNERSHIP LOCAL-AGENCY 'fJ / oZ1 <br /> TO INDICATE COUNTY-AGENCY' STATE-AGENCY' <br /> DISTRICTS' � FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS L� GAS STATION F—] 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE# TH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> /�?o.000e-Ill ✓�4/� CZ�� J= J/fy^ <br /> _ <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AR A CODE NIGHTS: NAME(LAST,FIRST) PHONE# ITH AREA CODE <br /> � J v zo 9/ qst -o��9 S3w-A 6,C ��4� lay s <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORS REEET ADDRESS / ✓ box b indicate = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> XU !0 7 L;oi-CDRPORATION = PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF r � CARE OF ADDRESS INFORMATION <br /> MAILING OgPTREET ADgRESSv ✓ box b indicate INDIVIDUAL [] LOCAL-AGENCY f� STATE-AGENCY <br /> U , C CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME /� S ,1 ZIP���O CODE ONE#WITH AREA COD2,7 rU <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F41 4-I- 2. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box lo indicate W­, SELF-INSURED 2 GUARANTEE 3 INSURANCE <br /> =5 LETTEROFCREDIT 6 EXEMPTION 99 OTHER C 4 SURETYBOND <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 SHOULDAE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED U ERPPL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MO TWDAY R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 2 (o <br /> LOCATION CODE -OPTIONAL CENSUS TRACT s -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 /> A <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNn QTORAGE TANK REGULATIONS <br /> FORMA(3/93) 3A-A7 <br />