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� STATE OF CALIFORNIA v - ; STATE WATER RESOURCES CONTROL BOARD `'°gr a 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A .., COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ��{I} 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FACILITY NAME y I Lt— S NEAREST CROSS STREET PARCELSj0PfIONAu ADDRESS } Aloe � STATE ZIP CODE SI PHONE R WITH AREA CODE - CITveytL - f�/✓� �x �CORpppATlpN Q IHDIVItYJAL �PARTNERSHIP � LflCAL-AGENCY Q COUtITY-AGENCY' � STATE-AGENCY• � FEDERAL-AGENCY' TO INDICATE DISTR4CT5' 'If owner d UST Is a public agency,Complete the Eogwdng:name d Supervisor aP Givisbn,seclbn,or oNice which operates the UST TYPE OF BUSINESS 1�1 1 G,4S STATION 2 DISTRIBUTOR � ✓ IF INDIAN 4 DF TANKS AT SITE E.P.A. 1.D.N(apfiooall ,��1 � RESERVATION 0 3 FARM 0 4 PROCESSOR [] 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional PAYS: NAME(LAST,FIRST) PHONE y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE a PH NE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,F ST) 8Z D Ll II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED ,P�y // ,g I-� CARE OF ADDRESS INFORMATION NAS,',J� 0it— Cf�n'J� iv MAILING O�RSSST��REET ADDRESS ✓ box b Indicate [� INDIVIDUAL LOCAL•AGENCY 0 STATE-AGENCY t STREET f t S CVL CORPORATION F-1PARTNERSHIP0 COUNTY.IGENCV Q FEDERAL-AGENCY r TAT ZIP CODE PHONE R WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM OF OWNER f CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS �1 , ✓ box to MiCaW 0 INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY I D IvAC(pw ' i�D r t]tj CORPORATION C� PARTNERSHIP L] COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE Zip CODE PHONE s W4TH AREA CODE V BOARD F EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise, T3� D O l N Y NGS, V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ ��bY�diwle 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND O 5 LETTEROFCREDIT 0 6 EXEMPTION © 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E II.v III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE M TWDA NEAR IP4 z ev-1-1 gAIC �/ Q - 5 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONALCENSUS TRACT# -OPTfONAi 9UPVISOR-DISTRICT CODE -OP170ML THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS r 3A-R7 FORM A(3*3)