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`jj U <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> D14 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA a '4: <br /> •Cit IfOR Nor. <br /> ©� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT F—] 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [�:] 2 INTERIM PERMIT 5< 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURES <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 12 n t 2/111/,L/ <br /> O <br /> ADDRESSNEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> 6 g�-6 Gv /oo d/ oore- oaf- 146 - sa <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA sa/ -V BOX <br /> TO INDICATE Q CORPORATION [ INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORQ IF INDIAN tj#OFTS SITE E.P.A. I.D.#(optional) <br /> v� RES✓ERVATION ] <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDSC 0042 <br /> GEN <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERCY CONTA T PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) 54, PHONE#WITH AREA CODE DAYS: NA (LAST FIRST) <br /> a�//¢ v o 38-?a �0 70¢�� 9>PHnNr Q DF <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LA9T.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEnn CARE OF ADDRESS INFORMATION <br /> d/GZan 0�0 15441)IC-7 <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL QLOCAL-AGENCY <br /> Q STATE-AGENCY <br /> a S— 0ja ' '060(f_ Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> s C'# sa s ao - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 2 '614 <br /> MAILING OR DRESS ✓ box b Indicate INDIVIDUAL Q LOCAL-AGENCY <br /> Q STATE-AGENCY <br /> TREET A <br /> AU °(�' Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP ODE PHONE#NTH AREA CODE <br /> s n e ,5-a/,-5- r.20 -a9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 F4]-1 o 1 of 5-10 3 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF.INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION 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.E 11X III. <br /> ff'OIFT <br /> HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PPLI A S AME RINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> X.- Arch, <br /> CAL AGE'146Y USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 0 <br /> diT a3 -7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> I d79& <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO MATION 16NLY. <br /> FORM A(5-91) FOROM3A•5 <br />