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STATE OF CALIFORNIA Ar ° <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A as . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY .� 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E__1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 1 1?-,&r- CA I "I v-S 3-. Lo <br /> ✓BOX CORPORATION F_� INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <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 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 0 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 CODE <br /> L is Cho 4 b 3--2-1 ) ) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i-}L.7 2---21 ) <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a�V)-4N )L <br /> MAILING OR STREET ADDRESS 4 v' box to indicate INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> )J 2.0 } '� Y c �) J �CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> c"O- I `-f 5 (ra 1---> 4 tv 3--2`--1 ( I <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL (�LOCAL-AGENCY STATE-AGENCY <br /> trj 9z 5-�->x� ' )n l§CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - -?3 I (-, o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> L✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.0 II.0 III.Im <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE-O#fIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESJ&IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGRTORAGE TANKtGUf. TNS 10.)4-4s <br /> FORMA(6-95) � %G � <br />