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two <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD +d� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A > - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ro <br /> MARK ONLY O I NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q T RMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT Q < AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS N TCR�B�TREET PARCEL#(OPTIONAL) <br /> IC �Oi��T W (-I/ Of I <br /> CITY N ME t STATE ZIP CODE AlTE PH E#WITH AREA ODE <br /> ca S??�� 3 <br /> ✓BOX CORPORATION 0 INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AG Y- = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '#owserni UST'sapublicage .=Plete Nela#owbg:napsdsge foldwis n,eedbnoroncewhicho oWnthe UST <br /> TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR0 ✓IF INDIAN I#OF TANKS AT SITE E.P.A 1.16.#(opfioneq <br /> RESERVATION ' <br /> Q 3 FARM O # PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA : NAME(LAST,FIRST) PM E#WI AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 117 <br /> NIGHTS: NAME(LAST,FIRST) NE#WI AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMA ON-(MUSf BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> AJAW� Z4 N ✓ RPORATION <br /> O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU E STATE ZIP_QODk E# ITHAREACODE <br /> 111. TANK OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREET ADDRESS V' EMirab 0 INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> CORPORATION O PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY X <br /> . STATE ZIP CODE HONE# ITN AREA CODE <br /> 40 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if question aris . <br /> TY(TK) HQ 4 4 -j0jl <br /> V. PETROLEUM T FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eosro in6cale 1 ELF-INSURED =2 GUARANTEE = 3 INSURANCE 0 d SURETY BOND O 5 LETTEROFCRmn O 6 EXEMPTION 1�T STATE FUND <br /> ESTATE RIND b CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF OEPOSn O Io LOCAL GOVT.MECHANISM O 990THER <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. <br /> THIS FORM HAS BEEN COMPLETED UNDE NALTY PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE Y MON AYNEAR <br /> GV67 / c?�7 .fi�IC• l Z/ S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <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 FOR�'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC STORAGE TANK REGULATIONS <br /> FORM A(6.95) .We <br />