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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD coif <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY 1'e NAME OF OPERATOR <br /> le V!e.W �� r�I 'IAl7Y <br /> 777 ( V`A '` N RE TCROSS STREE PARCEL#(OPTIONAL) <br /> � E r <br /> CITY NAME <br /> STATE ZIP ODE SITE PHONE It WITH AREA CODE <br /> CA q 5 ' C? <br /> TO It101Box CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY []COUNTY-AGENCY' <br /> DISTRICTS O STATE-AGENCY' (]FEDERAL-AGENCY' <br /> If ownerof LISTS a ottk egenq,ounpiete the 1o9awng name of sWeN'sorof&sbn,section or oMoe whk,operales the UST <br /> TYPE OF BUSINESSKS z DIAN 1 GAS STATION O 2 DISTRIBUTOR ✓IF IN #OF TANAT SITE E.P.A. I.D.#(optional) <br /> J❑-I 3 FARM Q 4 PROCESSOR O RESERVAT <br /> 5 OTHERION •� <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: NAME(LAST, RST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> ^�] t7 <br /> NIGHTS: NAME(LAST,F ST) PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME /Ay CARE OF ADDRESS INFORMATION <br /> 7 a t4 <br /> MA <br /> ILING O^R�STREET ADDRESS A ✓ bos to iidrale INDIVIDUAL Q I]LOCAL.AGENCY STATE-AGENCY <br /> (e)4 L- I k ��I. Q COflPORATION Q PARTNERSHIP 0 OOUNTY.AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATZIPCODE PHONE WITH AREA CODE <br /> I,IJ?V'b6LO, CA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N EFOWNER CARE OF ADDRESS INFORMATION <br /> �MW ,.A alp <br /> MAILINGOR STREET ADDRIE,S,Sp ✓ boxlo WMI8 I]INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> O <br /> 47 <br /> o+'�Y O CORPORATION (]PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL -AGENCY <br /> STATE ZIP CODE PHONE WITH AREACODE <br /> 1<t"Le r t-,k' GQ �3to 2ca4 F�ct_ SS3rj <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Ips to indicate O 1 SELF-INSURED Imo'2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND [__1 5 LETMROFCREDIT [=]6 EXEMPTION =]STATE FUND <br /> Q8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE RIND&CERTIFICATE OF DEPOSIT 1010 LOCAL GOVT.MECHANISM 099 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.❑ II� III.O <br /> THIS FORM HAS DATE <br /> BEEN COMP ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> mTANIE9WR�AME(PRIN 851G11A E n TANK OWNER'S TI ONTHrDAy/YEAR <br /> C ZI A X <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION It FACILITY#_ g <br /> EE E3 8 <br /> LOCATIONCODE•OPTIONAL DENSUSTRCTM TIONAL SUPVISOR-DISTRICT CODE OPTIONAL <br /> SY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS THIS IS A CHANGE OF SHIE I FORMATION ONLY. <br /> FORM A(B-B5) OWNER MUST FILE THIS FORM 0THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU110OR GE TANK REGULATIONS <br />