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1%fte .r STATE OF CALIFORNIA �� a +� STATE WATER RESOURCES CONTROL BOARD :vim, e UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A , COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C n ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE (, I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Sv�W��Gi v ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ypA CA ✓BOX Q CORPORATION O INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' l=FEDERAL-AGENCY' TO INDICATE DISTRICTS •80k9erd UST eafabkaW y,ovnpkNNablowng n dngery rdanuid,,sedlon«drkew kho rm%Ma UST TYPE OF BUSINESS �1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESVIF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(CAdanal) 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LVT,FIRST) PHON #WITEA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE (2�t�J �3 - ra „ NIGHTS: NAME(UST, ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION t�4 MAILING OR STREET ADDRESS ✓ b#aW#bwle O INDIVIDUALO LOCAL-AGENCY O STATE z(1(.` E D CORPORATION PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITU NAMEGv 3 STAT ZIP CODE HONE M AR DE/� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OWNERCARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa le YMkale O 14DIVIDUAL O LOCAL-AGENCY Q STATE AGENCY CORPORATION = PARTNERSHIP O COUNTY-AGENCY O FEDERAL.AGENCY CITY NAME STATE ZIP CODE HONE M TH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa rok1*0 1 SELF-NSURED O 2 GUARANTEE O 3INSURANCE O 4 SURETY BOND =5 LETTEROFCREDR =6 EXEMPTION =7 STATE FUND O 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE RIND&CER nRCATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICAT)NS AND BILLING: I.❑ 11.❑ III.a THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S"ITLE DATE MONTIUDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 41015113151-21 77��I!Y" LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL O T7,. � Zed -14-1--4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR'` '11 THE LOCAL AGENCY IMPLEMENTING THE UNDERGR( STORAGE TANK REGULATIONS FORMA(8-95) �#w 1"d