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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE m' ' <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NOOR FACILITY NAME NAME OF OPERATOR <br /> V FE-R- SYO f ' MS(Ff &65i&65iR 5ING <br /> ADDRESS 1 NEAREST 99,T114 R�CROSS STREET PARCEL f(OPTIONAL) <br /> IA6- H. ' 411 5 TAY <br /> CITY NAME G/w� (� STATECA ZIP fepSITE PHONE M WITH AREA CODE <br /> ([—�el�S 2 <br /> be BOX Q CORPORATION MDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> •I owner of UST is a public a ml.aan We the blowing name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS M 1 GAS STATION ❑ 2 DISTRIBUTOR Q RESV IF INDIAN ERVATION #OF TANS AT SITE E.P.A. I.D.#(optlanal) <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> /� <br /> EMERGENCY CONTACT PERSON (PRIMARY) ,(� EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: <br /> RAME M : ST.FIRS Fr M PHONE#�i� 20� WITH AREA CODE Z39 1 DAYS: NAME ST.FIRST) PH ' CODE <br /> 4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> (orme—e N1p-InroV— <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> 10A �IU` I CAfi�A ADORES_S INFORMATION _ <br /> fvi �Q(wJV <br /> MAILING OR STREET ADDRESS ✓ box to r4mle 3a.HOMOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> W ( C)vZ Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME Syy E� ZIP CODE PHONE WITH AREA CODE <br /> C fi` 41 5�3� ?,aR 141 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAJIQ OF OWNER r C CE OF AO KESS INFORMATION <br /> M LUNG ORS EET ADDRESS ✓ box to' DUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ')0 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ��� STATE ZIPODE � PHONE#WITH AREA t <br /> ma <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB`/ESR--Call(91!_6�t)3322-9669 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to i4cate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OFCRB)IT Q 0 EXEMPTION 7 STATE RIND <br /> Q s STATE RIND d CHEF FINANCIAL OFFICER LETTER Q 9 STATE RIND b CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANLSAI 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. 1.❑ II.❑ III•❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SI ATURE) TANK OWNER'S TITLE DATE ONTtUDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIUTY It <br /> ❑ WaN� " it <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT70NAL 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 INFbRMAbON ONLY. <br /> OWNER MUST FILE THIS FORM VJWE LOCAL AGENCY IMPLEMENTING THE UNDERGROUVRAGE TANK REGULATIONS <br />' FORMA(6-95) <br /> is <br />