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<A y '`eou" as <br /> STATE OF CALIFORNIA �� °aa <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 nCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 1:12 INTERIM PERMIT ❑ 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 /> in AP, csG - <br /> ADD ESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 22-&5- %I �`' S\I"- 14-I -- -- 2�3 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> -eami LKS� CA - Io3!B <br /> ✓BOX 92-CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owner of UST is a public agency,Mete the following name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS Cyl GAS STATION ❑ 2 DISTRIBUTOR Q RESVIFINCIAN ERVATION #OF TANKS AT SITE E.P.A. 1.0.#(optional) C�IL— <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COCODE"'0j <br /> t�K:-CEAQ. 11,3PLA-l') �i� S`�bc� KflYRW `'C-'I m t K- 5 KAP <br /> -- �--® <br /> NgTS: NAME LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA DE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ® g ONI <br /> MAILING OR STREET ADDRESSe <br /> bohyto lQ ate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P-c) _ W ' ✓ CORPORATION =PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> I 1 N Sd c.l -126-hal,6 —bv - b e l <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> i S`ToP t�1 a Nc- - <br /> MAILING OR STREET ADDRESS ✓ to mate Q INDIVIDUALQ LOCAL-AGENCY Q STATE-AGENCY <br /> ( 5 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME A STA Z� DE PHONE�WITHAREACODE <br /> m® <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -101 to <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to inmate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDrr =6 EXEMPTION 1717 STATE FUND <br /> Q 6 STATE FUND d CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM 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.❑ it.❑ IU.;R <br /> THIS FORM HAS BEEN CO ETED D R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINT 6 SI A E) TANK OWNER'S TITLE GATE MON YUYEAR <br /> LOCAL AGENCY US <br /> COUNTY# JURISDICTION# FACILITY# <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM0 <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> I <br />