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STATE OF CAl1FORWA Ani sI <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A "a•Y1 . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ® <br /> O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SIT <br /> 1 NEW PERMIT 3 RENEWAL PERMIT <br /> MARK ONLY A AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> ONE REM Q 2 INTERIM PERMIT <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> EOF OPERATOR y I S ykNu <br /> DBAORFACILITV NAME 'YE)[A��op�Vg �77JATloN Mkd rylZS•SHA6/dAF/ �~ PARCELS(OPTIONAD <br /> of S741L NI.IL-T L?5 R F� NEAREST CROSS STREET <br /> ADDRESS ✓ NAA �'� as <br /> LOf OV I V` STATE ZIP CODE V� SITE PHONE WITH AREA CODE <br /> CITY NAME CA 9fJ ,3 D <br /> I_ArHtior <br /> LOCAL-AGENCY <br /> FEDERALAGENCY' <br /> ✓ Box COUNfYAGENCY' STATE-AGENCY' O <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP DISTRICTS' <br /> •N owner of UST Is a Public ags .WrrpNre the foNowing:name of Supervisor of djvWon,wctbn,or office which OPW"thS <br /> SOF TANKS AT SITE E.P.A. I.D. (aplbTal) <br /> TYPE OF BUSINESS T GAS STATION 0 2 DISTRIBUTOR RESERVATION <br /> Q 3 FARM < PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-0Ptlon8l <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE S WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONES WITH AREA:DE s H CHAt'/ /a i /v- 7 G-7-11L d <br /> yPHONE S WITH AREA CODE NIGHTS: NAME(LAST.FIRS T) NES WITH AREA E <br /> NIGHT :NAM ti T.FIRST) n 2 2Q q <br /> - 2—f'1-1 Sq,� <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> HNaS .57hAQ9Ar1 tAAAI'"S Acv <br /> MAILING OR STREET ADDRESS ✓but btoMs 0 INOVDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> p CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP Cp�?.D PHONE S WITH AREA CODE <br /> 147'W d,a 6.4 Vl l7 <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) ?� 7z-3c6 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ha 6 i *v, A ✓d <br /> MAILING OR STREET ADDRESS ✓bMbInCNAu O INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> .4wx CORPORATION O PARTNERSHIP O COUNTY AGENCY D FEDERALAGENCY <br /> CITY NAME STATEPHONES WITH AREA CODE <br /> l r Qr 1 c4 ZIP D r 736-1776 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if quesbonsise.� <br /> TY(TK) H0 [4--F4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boy bNldP 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0•SURETY BOND <br /> O 5 LETTEROFCREDT D e EXEMPTION O 0 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PE LTY PERJURY,r TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'SN E(PRINTED&SIGNEE ERS TITLE DATE MONTWDAYNEAR <br /> ��'� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY t JURISDICTION x FACIL"t <br /> E D (o (o <br /> LOCATION CODE OPTIONAL CENSUS TRACTS OPTIONAL SUPVISOR-DISTRICT CODE -OPTA)NAL <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 FORT 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' ,STORAGE TANK REGULATIONS <br /> FORMA(353) OWNER <br /> FOROOOYlA7 <br />