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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3f o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED ITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FAfILITY NAME NAME OF OPERATOR <br /> 7vN E K6NW'-y'44 <br /> ADDRESS 'e . � A0 �A r� - NEAREST CROSS STREET PARCEL#(OPFgNAO 44,41 <br /> :ZT <br /> CITY NAME 'T STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> AC MPO CAv BOX <br /> 95220 <br /> T NDCATE D CORPORATION O INDIVIDUAL E-1 PARTNERSHIP (]LOCAL-AGENCY Q COUNTY AGENCY O STATE-AGENCY 0.FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O ( GAS STATION 2 DISTRIBUTOR RESERVATION *OF TANKS AT SITE E.P.A. I.D.*(apfbnal) <br /> Ex 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 2— <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,F ST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> q �i.ae o,%) 36T-':1t!1 <br /> NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) TH AREA COOP <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 11 CARE OF ADDRESS INFORMATION <br /> SA.rI� KfFi`-rA4LYAN <br /> MAILING ORSTREETADDRESS A^ p�� ✓ ba 10 Micas 0 INDIVIDUAL �LOCAL-AGENCY O srATE-AGENCY <br /> 35 5710 E' - 4 COI*7P0 dexwq(� Q CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> /OC4.-7 A CA ` 1Kzz& <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED OWNER CARE OF ADDRESS INFORMATION <br /> _? F A[- '4 <br /> MAILING OR STREET ADDRESS• ✓ box blMCM INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY <br /> 5,5z 9 E71 CORPORATION (] PARTNERSHIP [--1 COUNTY-AGENCY (] FEDERAL#GENCY <br /> CITY NAME' - STATE ZIP DE PHONE*WITH AREA CODE <br /> Aca,6+P� C14cKZZzf <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box toirdkala L::] I SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 A SUR Ery SOND <br /> I=5 LETTEROFCREDIT 6 EXEMPTION W 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.[--] it.[�? III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION* _- FACN-ITY. <br /> 54,Z-7 I_Z) D b D �/4 7 <br /> LOCATIONCODE -OPTIONAL CENSUSTRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ?iZa <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T4191S A CHANGE OF SITE INFORMA ION ONL . <br /> FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F010077AR6 <br />