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STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> CO PLETE THIS FORM FOR EAC CILrrYISTfE <br /> MARK ONLY ❑ I NEW PERMIT F RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY F <br /> ONE ITEM ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE hlill <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) tial <br /> DOA OR FACILITYNAME y1 / _ NAME OF OPERATOR ) <br /> A00 N ST CRO TREET PARCELAIOPrgNAll <br /> CI � STATE 2 COOT D� SITE PHONE,WITH AREA CODE <br /> CA L✓.� <br /> BOX <br /> TO INDICATE O CORPORATION a INOIVIDWL 0 PARTNERSHIP O LOCA CTS AGENCY C:]CWMY-AGENCY CD STATE AGENCY O FEDER4LAGENCY <br /> DISTRITYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR R /IF INDIAN x OF TAN T SITE E.P.A I.O.a(oplimA) <br /> D FARM Q 0 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> P <br /> NIGHTS: NAME(LAST.FIRST( PHONE r WITHAREACODE NIGHTS: NAME(LAST.FIRST) <br /> P <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM ��!H• CARE OF ADDRESS INFORMATION <br /> MaOR STREET ADDRESS 69 J�o� Q INDIVOM LOUSTATE-AGEWYTGQ CORPORATION 0 pARTNERsHIP CDUNTYAGENCY O FEDERAL <br /> AGENCY <br /> ITYN ME STAM ZIP CODE�'D l QNEAWI AREA CDOE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) F/l <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREETADORESS• J Www Q INDIVIDUAL a LOCAL-AGENCY STATE-AGF)gY <br /> =CORPORATION 0 PARTNERSHIP Q couNrY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4i4� n <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> m�buMkw <br /> [-,I I SELF INSURED n 2 GUARANTEE 771 O INSURMCE [--14 SURETYEOND <br /> Ll 5 LETTER CF CRECIT L7 6 EXEMPTION W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will he sent to the lank owner unless box I or II' checked. <br /> CIIECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL' III•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE GATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION N FACILITY N(1'02- � <br /> uLi <br /> LtXai10NC0f`}.• IOI'I/ONAI CENSUS TRACT a -OP TIJOf,INh ISUPVISOTCOOE -OPTIONAL <br /> U G U I {JAZ <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 /> FORM A(12911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A.R6 <br /> ;1�% �c/D <br />