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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3,„� e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE m <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED.SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 6 AMENDED PERMIT O 0 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBP OR FACILITY NAME _ Iwd '.�w NAME OF OPERATOR <br /> ��v' S v� a <br /> ADDRESS NEAREST CROSS STREET PARCELAIOPTIONAL) <br /> Po L- 1.,w t AVE <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 4 CA <br /> ✓ O CORPORATION NIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '&oas o(UST's apu k agency,mhplele the lok mg roma of supervisor01 dhaim,section aro0ke xhxh olHrates the UST <br /> TYPE OF BUSINESSGAS STATION O 2 DISTRIBUTOR 0 ✓IF INDIAN J#OFTANKS AT SITE E.P.A. I.D.a(optione0 <br /> RESERVATION <br /> 3 FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY JONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITYI AREA COD DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> / -33!V- -& <br /> IGHTS: NAME(LAST,FIRST) HONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM6Et/fj CARE OF ADDRESS INFORMATION <br /> — L <br /> MAILING OR STREET ADDRESS ✓ IKXtoae INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY Ypp Are- <br /> CITY NAME STATE ZIP CODE PHONEM WITH AREA CODE <br /> g ZS<G7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME,�OyyF OWNER CARE OF ADDRESS INFORMATION <br /> (19Cv <br /> MAILING OR STREET ADDRESS -/ ✓ hoxtoindmte Q INDMDUAL O LOCAL-AGENCY O $TATE-AGENCY <br /> pp �'�•• Y O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> aQ `::�1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ws k trate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE O A SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION O T STATE FUND <br /> 00STATE FUND&CHIEF FINANCIAL OFRCER LETTER I=9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 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.O it.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED A,SIGNATURE) TANK OWNER'S TITLE DATE MONTHJDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION k FACILITY N <br /> LOCATION CODE -OPTIONAL CE�fj T OPTIONAL $UPVISOR-DISTRICT CODE -OPTIONAL <br /> OPTIONAL ; <br /> [STRICT <br /> 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 V THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUP 'ORAGE TANK REGULATIONS <br /> FORM A(695) L Imill, <br />