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"oun es <br /> STATE OF CALIFORNIA AP cO <br /> STATE WATER RESOURCES CONTROL BOARD 3 ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F_� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM F_� 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE t <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME 01 OPERATOR <br /> . /1a c, r�A20 <br /> ADDRESS • NEAR ST CROSS STREET PARCEL#(OPTIO AL) <br /> 2600 Ad k <br /> CITY NAME/' STATE ZIP CODESITE PHONE#WITH AREA CODE <br /> NAME STATE <br /> 11 CA 11"15Z©4 -13(7 <br /> TO DIC TE F-1 CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 6Pr STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 ON <br /> 3 FARM a 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: E(LAST,FIRST) 20 r <br /> r2. - Zo <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: ME(LAST,FIRST) <br /> C.46 PHONE#WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 6 a4&� ad CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I box bindicate = INDIVIDUAL = LOCAL-AGENCY TATE-AGENCY <br /> Po ` CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STA <br /> /� ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME8 OWN CARE OF ADDRESS INFORMATION <br /> AdLM J <br /> MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL LOCAL-AGENCY AT <br /> �Q Q' CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME S T.4,TE ZIP CODE <br /> -7L,—(1101 <br /> / PHONE#WITH AREA CODE / <br /> to Z f JA 7L,— O J <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TI LE DATE MONTH/DAYNEAR <br /> 7-10- <br /> _/ 41 <br /> LOCAL AdENO USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � 1 � t 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I(��G �✓ <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 /> FORM A(5-91) FOR0033A-5 <br />