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up <br /> STATE OF CALIFORNIA a 1 ap <br /> STATE WATER RESOURCES CONTROL BOARD Y 4n� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE rA �� C44"Oft"', <br /> MARK ONLY ]� t NEW PERMIT Q 3 RENEWAL PERMIT D 5 CHANGE OF INFORMATION ll�N/O 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT E—] 6 TEMPORARY SITE CLOSURE 11 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) IF a1°\ <br /> DBA OR FACILITY NAME NAME OF OPERATOR 'O l Bl <br /> Fl 1In T Inc. D8/q F n .7— Ti are l�/G F/ ire s TrAve/ Pla zR t <br /> AD RES/ � NEA ST C SS STREET PARCEL N(OPTIONAL) <br /> �5 w /Zo s/OD t• 4 8094 <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> L D DI CA 9-6-2 �O <br /> I/ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL-AGENCY' <br /> 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 iK t GAS STATION F—] 2 DISTRIBUTOR Q ✓ IF INDIAN *OF TANKS AT SITE E.P.A. I.D.tt(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) j1HONEf WITH AREA CODE DAYS: NAME(LAST,FIRST) HONE#f WITH AREA CODE <br /> Meye.-, Mutt x/33 73V,- 3y3/ ohnsomn Delo $'00) 331- <br /> NIGHTS: <br /> 3 --NIGHTS: NAME(LAST,FIRST?�I., HONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HO E*WITH AREA CODE <br /> L e,- /1-9ft #3-5 - 3y 3/ J-pAm1on fie% 0 33 - 75 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATIQU <br /> T He, JO,�vs <br /> MAILING O STRE ADDRESS ✓ box bindicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0, 5&CORPORATION = PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE it WITH AREA CODE <br /> f3,--i ,� C, f L4_r YY3o -2 Nis :73 - (yoa <br /> III. TANK 0 NER INFORMATIO -(MUST BE COMPLETED) <br /> NAME OF OWNER CARE O ADDRESS INFORMATION <br /> n <br /> —To C. p�sl,vSmu ��d <br /> MAILING efR STRftT ADDRESS ✓ box to indicate INDIVIDUAL E::] LOCAL-AGENCY Q STATE-AGENCY <br /> 7 ORPORATION = PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME <br /> rr gm ^(6 STATE 21P CODE Z HN 35 IT7AREA CODE �D <br /> IV.BOA OF EGIUALIZATI UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions(/arise. <br /> TY(TK) HQ M44-161_11211 <br /> S <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box ID Indicate l SELF-INSURED 2 GUARANTEE O 3 INSURANCE (]4 SURETY BOND <br /> =5 LETTER OF CREDIT D 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: I.E II.X Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> s 701 <br /> LOCAL AGENCY USE ONLY ] 9 7;�'— <br /> COUNTY# JURISDICTION# FACILITY f <br /> m FTTI F40a47R <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(3/93) FOR=3A-R7 <br />