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66�VA �'3 <br /> P ��• C <br /> STATE OF CALIFORNIA .c <br /> STATE WATER RESOURCES CONTROL BOARD s ?� <br /> m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ac os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM F__j 2 INTERIM PERMIT F_� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> baa R FACILITY NAME NAME OF OPER TOR P <br /> A15DRESS NEARESt CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA `7��Z46 <br /> ✓ BOX INCORPORATION l�INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' (]FEDERAL-AGENCY' <br /> TO INDICATE \\ 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 t GAS STATION Q 2 DISTRIBUTOR = ✓ IF INDIAN 140 OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY 9ONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST),,y PHONE,#WITH AREA CODE DAYS: NAME f LAST,FIRST) PHONE#WITH AREA DE <br /> �d-7 /Gqo^ • 95 0 '�I Yf GL7tU /�/A J 460? <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATIO <br /> J�--/ © r ♦ L I�7 T//Q �' �' D <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE VHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNIR CARE VF ADDRESS IN ORMATION <br /> LLQ A GAv-t <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> RN CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE# ITH AREA CODE ! <br /> 'Tf�� j y —9 <br /> IV.BOARD OF EQUALIZATION UST STORAGf FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 [4--l- o— 7 9'141 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate, LF-INSURED UARANTEE 0'3 INSURANCE (]4 SURETYBOND <br /> O 5 LETTER OF CREDIT O 6 E MPTION 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.O II.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT*-OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br /> 07 1V. /o zs 96 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION' FORM B,UNLESS THIS IS A CHANGE OF SITE I MAnoN ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/93) Is 0 <br /> FOR0033A-R7 <br />