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_1� <br /> STATE OFCALIFORNIA "�soun ea <br /> STATE WATER RESOURCES CONTROL BOARD •• oma <br /> UNDERGROUND STORAGE TANK PERMIT AP LICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILTTY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / <br /> 2o47v, 1314 cIG--s NAMEOFOPERATOR <br /> ADDRESS <br /> NEARESTCROSSSTREET PARCEL#(OPTIONAL) <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH <br /> ✓ AREA CODE <br /> BOX CA <br /> TO INDICATE [:j CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCYED COUNTY-AGENCY STATE-AGENCY <br /> DISTRICTS [__1 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OZ ANKS AT SIT E.I A. I.D.#(optimal) <br /> 0 RESERVATION ) <br /> ❑ 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> E CONTACT PERSON ( Y EMERGENCY <br /> DAYS: (LAST,FIRST) x PHONE#WITH AR ODE DAYS: NAME(LAST,FIRST) PERSON (SECONDARY)•Optional <br /> - matin S a /irll sI - t. <br /> IGHTS: NAME(LAST,FIRST) - avfHONE#WITH AREA COD NIGHTS: NAME(LAST,FIRST) —- <br /> r <br /> II. OPERTYOWNER INFORMATION- OMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /"J'IP✓D /l K t.t.-I-'/Gc✓ >VI' aJ l4l�P5 #tC <br /> MAI LING OR STREET ADDRESS ✓ box In Indicate p Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CIN NAME P a D xjit O CORPORATION Q PARTNERSHIP D COUNTVAGENCY ED FEDERAI.AGENCY <br /> STATE ZIP CODE PHONE#WITHAREACODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDflESS INFORMATION <br /> S OL--e- 4 5 -71- <br /> MAILING OR STREET ADDRESS ✓ box blMicafe <br /> INDIVIDUAL (] LOCAL AGENCY L_J STATE AGENCY <br /> CRY NAME CORPORATION = PARTNERSHIP IJ COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE zip,;;ODE PHONE#WITHAREACODE <br /> IV. BOARD OF E9UAMTIOqMSLSjQBAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO <br /> V. PETROLEUM SIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bietlkale I SELF-INSURED 2 GUARANTEE 9 INSURANCE <br /> O 5 LE EROFCREDIT 0 6 EXEMPTION99 OTHER D 4 SURE BOND <br /> C <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> L❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANPS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTHlDAVIVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 'T Rora2rs- <br /> LOCATIONCOODE -OPTIONAL CENSUSTTRA�Y .pPTIONAL iSUPVISOR,3-DIISSTRICT CODE -OPTIONAL <br /> OT(UN 3 Ca VV9_3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • / • FOR6363AR6 <br />