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0 <br />I - <br />Ll <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />MPLETE THIS FORM FOR EACH FACIL(rY/SITE <br />MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />ONE ITEM u 2 INTERIM PERMIT �! 4 AMENDED PERMIT u 6 TEMPORARY SITE CLOSURE Q I <br />P, nii ivv,r.rrr_ ulenoMAA r!^Ki 2- AnnGCQQ - IKAI IQT AP 110MPI FTFI711 <br />DBA OR FACILITY NAME <br />OF OPERATOR <br />DAYS: NAME (LAST, FIRST) <br />�NAME <br />— <br />ADDRESS <br />NEAREST CROSS STREET PARCEL A (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />CITY NAME <br />CA <br />25 7,C21 <br />TO INDICATE CO PORATION INDIVIDUAL PARTNERSHIP LOCAL- GFNCY COUNTY•AGENCY Q STATE -AGENCY FEDERAL -AGENCY <br />TYPE OF BUSINESS t GAS STATION j� 2 DISTRIBUTOR <br />RESERVA%N <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />O 3 FARM 4 PROCESSOR n 5 OTHER <br />OR TRUST LANDS <br />r.n.ir APT nCOenN ioGIAAAMVI FMFRGFNCY CONTACT PERSON (SECONDARYI - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE WITH AREA CODE <br />e-nnu rTinsi iltu l�T []C fl^RAni CTCMI <br />I t vrrlrwn n•i viunl-.l Iv.. -- -- <br />11. rnvrCn ------ I <br />CARE OF ADDRESS INFORMATION <br />NAME <br />NAME <br />MAILING OR STREET ADDRESS <br />� box to indicate INDIVIDUAL OLOCAL-AGENCY Q STATE•AGENCY <br />/ <br />yn� N, <br />I CORPORATION [] PARTNERSHIP = COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE PHONE #WITH AREA CODE <br />/ _ <br />III. TANK OWNER INFORMATION - (MUST BE GUMFLE I IzU) <br />NAME OF OWNER S 12 Ile_ CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />CORPORATION' Q PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME STATEZIP CODE PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Uall (91b) 3z3-9555 a questions arise. <br />TY (TK) HQ 14 4- „Z y� <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 CJ 4 SURETY BOND <br />5 LETTER OF CREDIT •=1 6 EXEMPTION 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 ch <br />[CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />tPPLICANT'S NAME (PRINTED & SIGNATURE) I APPLICANTS TITLE DATE MONTWDAYNEAR <br />I Orel An;:NCV IISF ONI Y <br />COUNTY # JURISDICTION # FACILITY # y <br />- - - ----- - -- - <br />LOCATION CODE OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL <br />Q/ v3d0v— <br />nunT1AN ANI Y <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OH MOHt PtHMI I ANYUUAIIUN • rvnlw D, UI'4Lr-QQ IMO iJ r..,ll.,l.uw.a w -._.. _.---- <br />FORM A (12-91) FILE THIS FORM WITH j00CAL AGENCY IMPLEMENTING THE UNDERGROUND ST GE TANK REGULATIONS / FOR0033A-R6 <br />t <br />