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1`tSoUn •4 C <br /> STATE OF CALIFORNIA P ° <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a 4, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [:] 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE ©/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR ` <br /> k. owtt.•tt c 's C'M�sp1 � R_*'y ►"<•�li ST�� <br /> ADDRESS NEAREST CRO SSTREET PARCEL#(OPTIONAL) <br /> 1 -751 ostwl I`c ,' o✓� <br /> CITY NAME MG c 9 STATE IP 95-3 6 SITE PHONE- - I/I e)CLOD.E <br /> TO INDICATE /D CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY � STATE-AGENCY 'O<FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LA T,FIRST PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 1-F .' Z_of Y6 - 6&0 S PHONE 9 WITH AREA <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S _ �•' 2D `/3- ICO 0 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �//�� I �1� I CARE OF ADDRESS INFORMATION <br /> YJom0I C- `> [f� ��` G✓t cCS <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> IV o 5 /v e9 le ����q �CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME �'`'f� STATS' ZIP CO E Z Q G/ PHONE#WITC6S I-5 <br /> H AREA C <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) C7JV 7 V <br /> NAME OF OWNER �- CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box to indicate INDIVIDUAL E�j LOCAL-AGENCY STATE-AGENCY <br /> []CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO E4I4_1- 5 i <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 E:1 4 SURETY BOND <br /> = 5 LETTER OF CREDIT 6 EXEMPTION El 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.F-1 II.F11 III.O <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 5-T bop•( 17 <br /> 3 ; !_Z �' z 3 7 <br /> ------- ----- --- -- - <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I , —L l `c 3 <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(tz 91) FILE THIS FORM WITH THE LOCAL 0 AGENCY IMPLEMENTING THE UNDERGROUND STORAGREGU S <br /> 0ETANK <br /> FOR0033A-R6 <br />