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0 <br /> STATE OF CALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> r mom, i o° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> i <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F� 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMY�LA` 5ty O A4 NAME OF OPERA�Q���� 0 ca ��M�•- <br /> ADDRESSNEAREST CROSS STREET PARCEL x(OPTIONAL) <br /> 601 J t�GTTL4fm14 ,1/ LjjMF C eZ44 6e 1,IV, <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITHA CODE <br /> LAI c (� � Sa�v ca Rsa �� �� s �AREA <br /> V BOX <br /> TOINDICATE D CORPORATION INDIVIDUAL 0 PARTNERSHIP [] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> 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 Q ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> j GJO TI-490'p- -Log 3630715 s7lN&m ,Il Lc Cpl . , <br /> NIGHTS: NAME LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME AST,FIRST) . PHONE#WITH AREA CODE <br /> S l &U Tapek 9 57 5/0 LQl 20e7 7 21) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME r CARE OF ADDRESS INFOR ATION <br /> 6 <br /> C7r -!�r = l 1 o4rli✓ <br /> MAILING OR STREET ADDRESS / �/ ✓ box to Indicate tj INDIVIDUAL E:1 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 <br /> O F f/�v L /T�i CORPORATION PARTNERSHIP EDCOUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME lSTATCODE #WITH AREA CODE <br /> q aog, c STATE ZIP q sa v PHONE a� 36s d ig <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 000 F St r4 X0 <br /> MAILING OR STREET ADD RESS //y��,, / ✓box to indicate INDIVIDUAL E::] LOCAL-AGENCY (]STATE-AGENCY <br /> O f� �!'I Rd L � O CORPORATION PARTNERSHIP 000UNTY-AGENCY (� FEDERAL-AGENCY <br /> CITY NAMEr �,\ �� V STATE ZIP CODE PHONE#WITH AREA CODE <br /> l.�Alf 0- cl (Aj 1 qs a410 2-® 9 -36,-;-o?1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-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 b Indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT Q 6 EXEMPTION 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.[m if.= III. <br /> THIS FORM HAS BEEN COMPLET UNDER PENALTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> �- /�°l s' <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m o <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 71SUPVISOR-DISTRICT CODE -OPTIONAL I _ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMA ON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIS <br /> FORMA{319'3) FOR0033A-R7 <br /> 0 0 <br />