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pg®......s ° <br />STATE OF CALIFORNIA hr <br />s <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A, o-0 <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 ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I_ FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) ® 23 <br />DBA OR FACILITY NA E <br />NAME OF OPERATOR <br />DAYS: NAME ( ST, FIRS <br />Cr <br />HON <br />ADDRESS 1 <br />l <br />NEAREST CROSS STREET ° <br />COLUtV <br />PARCEL # (OPTIONAL) <br />CITYNAME <br />STATE <br />ZIP CODE <br />SITE PH NE # WITH AREA CODE <br />Q FEDERAL -AGENCY <br />CA <br />11,57.%49 <br />L 4-:02.7- 11 <br />✓ BOX tKCORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY ° Q STATE -AGENCY' Q FEDERAL -AGENCY' <br />TO INDICATE DISTRICTS <br />° M 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 Q 2 DISTRIBUTOR <br />® <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM 0 4 PROCESSOR Q 5 OTHER <br />RESEIRVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME ( ST, FIRST) <br />Mk <br />CPIC # W TH AREA COQ <br />2Z tYi' L <br />DAYS: NAME ( ST, FIRS <br />Cr <br />HON <br /># WI AREA CODE <br />/YJ <br />NIGHTS: NAME (LAST, FIRST) <br />PHO E # WITH AREA CODE <br />.to <br />NIGHTS: NAME LAST, FIRST) <br />PHO <br /># WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />t <br />DATE MON Y/YEAR <br />t�tVPV aMr <br />MAILING OR STREET ADDRESS <br />✓ box to klicate Q INDIVIDUAL <br />Q LOCAL -AGENCY <br />Q STATE -AGENCY <br />17 - D <br />CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />I ZIP COPE <br />WITH <br />(9m <br />REA CODE <br />2 - <br />NAME POFWN R <br />CAR OF ADDRESS INFORMATION <br />DATE MON Y/YEAR <br />t�tVPV aMr <br />J 41 <br />`l <br />MAILING OR STREET ADDRESS <br />✓b&10 indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />• & <br />CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />6/93 <br />STATE <br />ZIP CO EPHON, <br />4AK-le3 <br /># WITH REA CODE <br />J\ <br />•• ques ions <br />©m© -q 11151 <br />✓ box to indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND <br />Q 8 STATE FUND & 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. ❑ 111. <br />® IZI S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, JNP T PE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK NAME (PRINTED &SIGNATURE) <br />TAN TITLE <br />DATE MON Y/YEAR <br />�l <br />J 41 <br />`l <br />COUNTY # JURISDICTION # FACILITY # <br />❑ I I I I I I I <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 />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (6-95) <br />