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• FSUV-CpS <br /> STATE OF CALIFORNIA r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �. <br /> Cit iwpM N� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1NEW PERMIT n 3 RENEWAL PERMIT $ CHANGE OF INFORMATION 7 PERMAN SITE <br /> ONE ITEM 2 INTERIM PERMIT F 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE r' ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILLT,Y NAME �� NAME OF OPERt1TOR _ <br /> _ � , _� <br /> ADD ESS \ � ; NEARES SS EET PARCEL#(OPTIONALI <br /> r ja <br /> I x� - 1 <br /> p �_ <br /> CITY NASTATE" '"I ZIP C SITE PHONE#WITH AREA CODE <br /> -- 1 r K r ci 11 CA <br /> sq? <br /> TO INDICATE CORPORATION INDIVIDUAL CI PARTNERSHIP 0 LOCAL-AGENCY u COUNTY-AGENCY ii STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSt GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION �7 <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS � F �• , <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAP-MAME(LASJ.FIRS PHONE.#WITH AREA CODE DA NAME(LAST,FIRS/T-) <br /> NIG e LAST FIRS PHONE#WITH AREA CODE N 1.l.tilC 11�P/Y� ��(, <br /> �D SPHI <br /> �� HTS: NAME(LMA LlAST,FI ST) <br /> --- , o .10&--�3?S-83o 1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �, CARE OF ADDRESS INFORMATION , <br /> \ tel u O �Sf 4 �c cOri L q C (a <br /> MAILING OR SIRE IT ADOISS ✓ box b indicate INDIVIDUAL LOCAL-AGENC STATE-A CY <br /> a 5U LA& &Y,t � ORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> o 5"61 7,3, b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME pLCW ERCARE TCARE OF ADDRESS INFOR TION s <br /> t U,, M, <br /> MAILING OR ET AO RESS i ✓ box to indicate INDIVIDUAL LOCAL-AGENCY _1 STATE-AGE NC <br /> CORPORATION _i PARTNERSHIP C COUNTY-AGENCY J FEDERAL-AGENCY <br /> CITY NpMF STA ZIP CODE PHONE#WITH AREA CODE <br /> ` Gca ,� C' u I � ���yn� <br /> IV. BOAR F EQUALIZATION H&STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ '4L, ,-�7 <br /> -3141 . 517J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE u 3 INSURANCE J 4 SURETY BOND <br /> 5 LETTER OF CREDIT J 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 checked. <br /> /// <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= It.F— III <br /> THIS FORM HAS BEEN OMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED& E) APPLICANTS TITLE DATE MONTH/DAYrVEARc <br /> F1!4 J A-1 C SILYIICA� iuLcal,. a4 -2 <br /> LO AL AGENCY YASE ONLY .y <br /> COUNTY# JURISDICTION# FACILITY# Opll p f '� <br /> :3_ ? <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 SI ON ONLY. <br /> '& <br /> C;rt a;iz 9t1 FILE THIS FORM WITH, AGENCY IMPLEMENTING THE UNDERGROUND ST TANK REGULATIONS <br /> FCR0033A-R6 <br />