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STATE OF CALIFORNIA <br /> W't sc�i <br /> STATE WATER RESOURCES CONTROL BOARD d� e S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA - .,ro <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> NEW PERMIT /'-� <br /> ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SI <br /> MARK ONLY ❑ 1 IJ{L� <br /> 2 INTERIM PE <br /> ONE ITEM ❑ RMIT ❑ 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUSSTT BE COMPLETED) <br /> NAME <br /> ofPp eRATOR <br /> DB OR FACILITY AME /�. L-vva . s C!, <br /> V-�//I+ NEAREST CROSS STREET ^ V•/l <br /> / PARCEL#(OPTIONAL) <br /> ADDRESS --� ! ,Yl` <br /> STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> CITY AME y ®_ CA <br /> ✓ BOR 000RPORATION^'•,—ED INDIVIWAL 0 PARTNERSHIP LLOCC SENCY 0 COUNTY-AGENCY' O STATE.AGENCY' O FEDERAL-AGENCY' <br /> DISTRITO INDICATE <br /> 'Hmmeroi USTu apu55c aganry.wmpleta Ne lalbwNg:namedslgarveor#iaMsion,swtim owKc#whidt aparere#the UST ✓IF INDIAN MOF TANKS AT SITE E.P.A LD.a(optioneQ <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> 0 3 FARM ❑ 6 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PH NEI ITH AREA CODE DAVS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> EDAYS: N E( ST,FIRST) — O ]IE PHONE a WITH AREA CODES: NAME(LAST,FIRS PHONE a TH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> �I <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME ,��,,,,�� �� Qnn <br /> S `qq4k L .a ✓ moo nNCate 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> MAILING OR STREET ADDRESS 0 CORPORATION D PARTNERSHIP O COUNTKAGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER a-41� <br /> ✓ Wxtondirate 0 INDIVIDUAL 0 LOCA4AGENCY 0 STATE AGENCY <br /> MAILING OR STREET ADDRESS <br /> 0 CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4:K- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓6ax to irAicate I BELFINSUPED O 2 GUARANTEE D 3INSURANCE O A SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION00 7 STATERIND <br /> O B STATE FUND&CHIEF FINANCIAL OFFICER LETTER 1� 11 i9 STATE FUND CERTIFICATE OF DEPOSIT 016 LOCAL GOVT.MECHANISM 99schecked. <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) <br /> TANK OWNER'S TITLE DATE MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION# FACILITY :3 <br /> COUNTY# � a 31X7 <br /> SUPVISOR•DIS CODE -OPTIONAL ^5 <br /> LOCATION CODE -OPTIONAL C-11569:5 RACT N .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 /> OWNER MUST FILE THIS FOTHE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK GULATIONS <br /> F�TH <br /> FORM A(6-95) ��+1 • q <br />