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STATE Of CALIFORNIA ^• �. <br /> STATE WATER RESOURCES CONTROL BOARD j m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> • Y/ p <br /> ry. <br /> C•tno J <br /> COMPLETE THIS FORM FOR EACH 6ACILITYISITE <br /> !HARK ONLY ❑ 1 NEW PERMIT ❑ D RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 MANpgED 3 E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE r I <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /SLoV� C�, FV2o� <br /> ADDRESS NEAREST CROS-STREET PARCELa(OPTIONAL) <br /> CITY NAME STATE I ZIP CODE SITE PHONE s WITH AREA CODE <br /> rt CA -7/v Box <br /> TO INMATE O CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAUADENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR a ✓ IF INDIAN 18 OF T KS RESERVATION <br /> AT E E.P.A. L D.a/optimal) <br /> Q 3 FARM Q A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY C PERSON (SECONDARY)•optional <br /> DAYS:IN,OME(LAST,FIRST) PHONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> xo (fe U — -7-7,r—Vrov <br /> NIGHTS:NAME( T.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#NTH AREA Con, <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREOoS V ,n(�Y <br /> ET ADDRESS / (^/ '/mAnWAA Q INDIVIDUAL Q LOCAL AGENCY Q STATEAGENCY <br /> 0 1 O D mo I Lt4_p Q CORPORATION Q PARTTER&w Q COUNrY.MENOY p FEDERAL-AGENCY <br /> CITY NAMEBTATE ZIP CODE AREA CODE <br /> b t 4�76-- <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER a5 CARE OF ADDRESS INFORMATION <br /> Sww•c <br /> MAILING OR STREET ADDRESS ✓bo.CAltlkm Q INDIVIDUAL Q LOCAL-AGBICY Q STATEAGBICY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAOEENCY Q FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <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-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ m.n iriekae Q I SELF-INSURED Q 2 GUARAMEE Q 3 INSURANCE Q A SURETY BOND <br /> O s TEn EROFCREDT O s 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: L O 11. NL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY µ/ <br /> COUNTY# `/Q Ui6 JURISDICTION• FACILITY <br /> JC (7U <br /> LOCATION CODE -OPTIONAL CENSUS TRACT Y-OPr10NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> D Z O U Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FCR=A 5 <br />