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'LpOVA - <br /> C <br /> STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY r-1 T NEW PERMITI� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q7 PERMANE CLO SITE <br /> ONE REM O 2 INTERIM PERMIT 1-7 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE II <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) _ -- <br /> DBAORFACILITY NAME N OPERATOR <br /> S`j <br /> ADDRESSNEAREST C SS STREET PARCEL#. ZONAL) <br /> CITY NA SITE PHONE a WITH AREA CODE <br /> `(� CA `J - - a <br /> T Io NDI RTE 14 CORPORATION 11 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY =1 COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,complete the following:name of Supervisor of division.section,or o#ice which operales the UST <br /> TYPE OF BUSINESS MA I GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opsonag <br /> RESERVATION — <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS L bo In IV.ec- <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> J7AYS: NAhQE'LAOST,F RS� \ PHONE a WITHACO�� D Y : NAME(LAST,FIRS ti, pHpry H <br /> (`'}(- T : AME(LAST FIRST) \\ PHONE#(—WITITTHfAFF DEE, NIGHTS:NA E( T,FIRST) OPHH'70p`--E 1$TH ABEAA�O <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME,`. \ 0� CARE OF ADDRESS INFORMATION <br /> MAILI ORS BEET APQRESS ✓box bbsbate INDIVIDUAL ED LOCAL-AGENCY E:3 STATE-AGENCY <br /> CORPORATION D PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STA ZI OpE, PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OFOWNER ` � C �� ' CARE OF,ADDR SSINFORMATn <br /> rCJ7• r c \S <br /> MAI ORSTREET ESS [ ( .J ✓ boa olMkab INDIVIDUAL O LOCAL AGENCY 11 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY E 0 STATE Zy53 PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9116))33222.9669 if questions arise. 4 <br /> TY(TK) HQ 4 4- - —Fa�L� �I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindicale 1 SELF-INSURED ED 2 GUARANTEE O 3 INSURANCE O 4 SURETYBOND <br /> O 5 LETrEROFCREDIT O 6 EXEMPTION O Ss 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.=1 II.O II"LTJ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONT AYNFAR <br /> c- "S M VITG <br /> LOCAL AG NCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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 /> FORMA(393) <br /> OWNER MUST FILE THIS FOR jr THE LOCAL AGENCY IMPLEMENTING THE UNDERGROfSTORAGE TANK REGULATIONS <br /> Fpi00311AT <br />