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STATE OF CALIFORNIAo95- <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYMTE +� <br /> MARK ONLY _01 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 0 2 INTERIM PERMIT E::] 4 AMENDED PERMIT E—] 6 TEMPORARY SITE a 0SURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME �� + NAME OF OPERATOR <br /> t J1,0 P r v4B�6dw�s /Y1 <br /> ADD E Sel' NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CI NAME_MfA` � STATE ZIP ODf S�/ SITE}-SON # ITH Ag yO <br /> .Pl CA (OCACU (D- -/�fo� <br /> ✓BOX CORPORATION Q INDNIDUAL [__1 PARTNERSHIP ©LOM.AGENCY COUNTY-AGENCY' [] STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '9 owner of UST is a public agency,complete the following name cl super fsorof division,section or oKce which operates She UST <br /> TYPE OF 13USINESS 1 GAS STATION a 2 DISTRIBUTOR Q ✓IF INDIAN Ift OF TANKS AT SITE E.P.A. I.D.#(aptiarra1) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR X <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D S: NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I <br /> NIGHTS: NAME(LA T.FIRST) PHONE#WI H AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM /f CARE OF ADDRESS INFORMATION <br /> IAA IVIG OR STREET AD RES -,Uf'r - y✓I box to hficate ED INDIVIDUAL Q LOCAL-AGENCY I� STATE-AGENCY <br /> .e +� - ,�I CORPORATION C3 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY ' <br /> M - STATE TEP,GE Py0 #WITH AREAE <br /> rNA <br /> tL7.C <br /> 1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N ME OF OWNER <br /> DT_R� <br /> DDRESS INFORMATION <br /> 606-21 e ►U r�rS <br /> AILING OR STREET ADDRESS ✓ box toWicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY I <br /> ✓n`•J1 CORPCATION PARTNERSHIP COUNTY•AGENCYh_ FEDE <br /> RAL-AGENCY <br /> LA ZSPC AM PHtE W R CODS i <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - /014 <br /> I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boslolnd'rate 1 SELNNSURED Q 2 GUARANTEE ©3 INSURANCE ED 4 SURETYBONO {]5 LETTER OF CREDIT [] 6 EXEMPTION7 STATE FUND <br /> [�8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND s CERTIFICATE OF DEPOSIT Clt] M LOCGOVT.MECHANISM Il OTHER i <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing wilNbe sent to the tank owner unless box I or II is checked. <br /> K <br /> ECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q 11, 111. <br /> EJ <br /> I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT i <br /> L;;�07E S NA E(P l IGNATURE) TANK OWNER'S 71TLEyy'A DATE <br /> MON THID YlYEAR <br /> � o <br /> LOCAL A ENCY USE ONLY d A/ r <br /> COUNTY 0 JURISDICTION FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SVPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6-85) <br /> a <br />