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�eoua e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W Qom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ne <br /> •C��IR�a N� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' <br /> 1. FACILITY/SITE INFORMATION&ADDR SS• M T BE COMPLETED) <br /> DBA OR FACILITY NAME yt)EG I G AME OF OPERATOR <br /> e, nJ b LLQ. <br /> ADDRESS �/ NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> f 40 95P C — �'�141V7 C C c/C� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TO INDICTE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSt GAS STATION i. 2 DISTRIBUTOR Q ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> rirkd Ph 510 537 -75-91 <br /> IGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> r 0Lo -1974 PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME f CARE OF ADDRESS INFORMATION <br /> I <br /> e. <br /> MAI-LING OR STREET AOD�E)SS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> �2`7 3 JKAF 61 VI ev f Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY =FEDERAL-AGENCY <br /> CITY NAME ' STATE ZIP CODE HONE#WITH AREA CODE <br /> N 21(C e cr} C1 o qt <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Nt2-- 1 C <br /> MAILING OR STREET A DRESS ! I/ box bmdicate = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> q"6 2_4 3 (IN 4 I Qw V Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> n1 JI f'e Ct '-0 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 F41- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate (Q t SELF-iNSURED Q 2GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 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: 1.❑ II.t III.❑ <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 TITLE - DATE MONTWDAYNEAR <br /> � <br /> a- KAH Q,reseh} 1 t - \$ - <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# L�a <br /> ❑ �' l IF -7 1 y3 O <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 /> FORM A(5-91) FOR0033A.5 <br />