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t � `boun cs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W 49 !b <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA ; _''_ , os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT E; 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION a 7 'PI664b0l.7 CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORa O4F�CILLTY NAME l 9lticRX c_Ar^ S�c� NAME OF OPERAT.DR <br /> C_r2 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> lC�qo P� �: acx� wC,—N-_VA0o <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AR CODE <br /> Stec-� � CA q 5�1s 2 ct31 X 8sc> <br /> TO INDICATE G;KORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY DISTRICTS' Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <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 Q t GAS STATION Q 2 DISTRIBUTOR Q RESERVATIONV IF INDAN Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHOVE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> to Cj31 - �cAgo <br /> NIGHTS: NAME(LASI,FIRST) PHO44i#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> SSS 13 Z>3- 1M 4`09 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A cAA St�.se v. �JZt <br /> MAILING OR STREET ADDRESS ,��✓,box��b Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> G20c> (—Z5��� ST LrG RPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> ' CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNfR CARE OF ADDRESS INFORMATION <br /> c e vs- %. -c.L G• 6- _ c.A -t�-��, s-�•v� <br /> MAILING OR STREET ADDRESS ✓box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> go E_ s��� S-� E .�RATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COPE PHONE#WITH AREA CODE <br /> cry q2zqz> 1).L3 713 -7qo X L.858 <br /> IV.BOARD OPtQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - `,4- eRR <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box loindicate Q t SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> EZ;'3 LETTER OF CREDIT Q 6 EXEMPTION 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: 1.F] it.� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> !Ta� <br /> OWNER'S TITLE DATE MONTWDAYIYEAR <br /> IZ -17 <br /> LOCAL AGENC USE ONLY <br /> COUrnNTY# JURISDICTION# FACILITY <br /> " t✓ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT -OPTpNAL <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(3/93) • FOR0033AA7 <br /> 1 <br /> _U_�6 W <br />