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n�bOV- <br /> STATE OF CALIFORNIA �� . o? <br /> STATE WATER RESOURCES CONTROL BOARD n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °• „a N <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE[TEM a 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> (31 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OPERATOR <br /> ADDRESS NEWSTCROSS SjREE /� PARCEL xi(OPTIONAL) <br /> CITY NAyly� STATE ZIP E SITE PHONE a WITH AREA CODE <br /> //v BOX 3 o9-z39-3zsz <br /> ✓ BOX �Q CORPORATION /�y.n.uIVIDUAL <br /> TO INDICATE e�/K/ Q PARTNERSHIP Q LOCAL-AGENCY QCOUNTY-AGENCY' QSTATE-AGENCY' Q FEDERALAGENCY' <br /> DISTRICTS' <br /> 'If owner at UST is a public agency,oomplel a following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN X OF TANKS AT SITE E.P.A. I.D. (optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOROTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: <br /> �r NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> " '� trt S —� �laA 'r ; rf 1 SS <br /> NIGHTS: NAME(LAST.FIRST) y ' PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) — PHONE s WITH AREA CODE <br /> ,o N 1, lA <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME // _ [ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> t r� I � ,. �1 s biro tate <br /> IQ INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ^ S � ORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CY� <br /> CITY NAME ` STATE ZIP CODE PHONE/WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME F OWNEF3 CARE OF PRESS INFORMATION <br /> MAILING OR STREET VDRESS I v / ✓ box b irbicats Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> f �rj✓w / i<.'l t__ �I I ji(� f�� it J ©CORPORATION Q PARTNERSHIP Q] COUNTY-AGENCY QFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> �� L 657 0 -3 -Z71 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- -1 t9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box ID indicate Q(I SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE Q 4 SURETY BOND <br /> LTJ 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: I.= II.F7 III. <br /> THIS FORM HAS BEEN COMPLETED UND R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNE OWNER'S TITLE DATE MONTWDAYNEAR <br /> I <br /> 4- L / T�;Itv,A4,0 Mw'(il <br /> LOCAL AGENCY USE ONLY ZJ q <br /> C�OUNTTYY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT m -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 D'EOR1tAT1 Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3(93) // FORom3A•R7 <br />