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• PESpU�C(�C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM E] 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS N REST CROSS STREET PARCEL#(OPTIONAL) <br /> +wu l?�Vi►^ sv� ark-, Larsz <br /> CITY NAM k�`©rl STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX IN CORPORATION D INDIVIDUAL E::) PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY' Q 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 1 GAS STATION 0 2 DISTRIBUTOR Q ✓IF INDIAN 111 OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DP�YS: NAME LAST,FIRSTI PHO E#WITH AREA CODE,, <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> � � <br /> NIGHTS: NAME LAST,FIRST) PH E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E ! CAREOF ADDRESS INFO M TION <br /> Li iavu 1 � i ►>� p�u'1 ter . <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> F0, 0201 1 1 W CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 0!a1�0,_c7 TA 7t;S'.14'_1 A1 °-37—'3 c:7`131 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NyME OF QWNER CARE OF ADDRESS INFORMATION <br /> ,.( Ct^,l.� LNL'fiibGtrI <br /> 1_7 ax, t- � no, <br /> MAI ING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY = STATE-AGENCY <br /> —70 I W CORPORATION PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME EaTE ZIP CODE PHONE#WITH AREA CODE <br /> I� 175"Z211 -0711 q <br /> �0 -� c 4 LJJ'-z' 9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 -100-4fFEM <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> D 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE RIND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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. 11. Ill.e�' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT _YY <br /> TANK OWNER'S LIIAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> 4/17/1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# I�D aZ�7 <br /> FT-1 nof07q <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORIV THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO10 <br /> TORAGE TANK REGULATIONS <br /> FORM A(6.95) T /Q <br />