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I <br /> QURc�y <br /> STATE OF CALIFORNIA .P ? <br /> 7 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE o ' <br /> I. FA <br /> ACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBCILITY AM 64-57'•-''Y NAME OF OPERATOR <br /> ADDRES,�ss NEAREST qROSS STREET PARCEL#(OPTIONAL) <br /> l O� Gvi�5`7" JCS rr'T �c s� vc 46�e'- t>e�l 4"--/ _'4r'—/ <br /> CITY.NAME/ STATE ZIP CODS SITE PF{OIVrpE WI H Af, <br /> CA <br /> ✓BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY` <br /> TO INDICATE DISTRICTS <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 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION Q �.,`�'- <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAY .oNIAE(LAST,FI S1FiOE�WJyFi AREADE DAY :fJgM�,(LAS�,FI13,S7 � r P4HOty[_#wITREA_CODE, <br /> ,I�j��( I` �Z1�J �NERJ CODE NI NAME(LAST,FIRST_757-53 ) ��P�QNJE#V111 'A�REA�C, <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) "G'7f f`^ TlJ� GX 1 �• <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> G �y o"L eo"4 Ac <br /> MAILING OR STREET ADDRESS ADDRESS ✓ boxto indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> J <br /> 94 ,�y iG / � _r4c.� Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY t1M � STATSCOZ© P,kL kH j^ACODE� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /'/y' (�"�''+LY�a� <br /> NAMCARE OF ADDRESS INFORMATION <br /> MAI G OfISTREET ADDRESS +�- ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ��/ �'� ~ Q CORPORATION Q PARTNERSHIP Q CCOOUNTY•AGENCY Q FEDERAL-AGENCY <br /> CITYAIAh�EJ _ STATE ZIP �Q (G�*✓"+ Ci E "Ot 3��'+� <br /> IV. {BOARDOFFEEEQUALIZATION UST STORAGE FEE ACCOUNT NUMBw!ERRT1-Call(916)322-9669 if questions„arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTEROFCREDIT Q 6 EXEMPTION Q 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM 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.❑ 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&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# r <br /> ❑ ,/ifs <br /> � -:IIr3 RX <br /> LOCATIO"ODE -OPTIONAL C SIS TPACT# -OPTIONAL S%VJ80R-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 FORMA(6.95) OWNER MUST FILE THIS FOR&H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRYS STORAGE TANK REGULATIONS <br />