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,'noun e <br />rC <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT 0 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 07 PERMANENTLY C`LI SSSLSITE <br />ONE ITEM 2 INTERIM PERMIT AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />1, rMVILl1 I/ i IIYrVf1rY1M1rVr\ of NL/Nf1 CJJ- tIY1V9 1 OC VVIVWLCI CuI <br />DBA OR FACILITY NAM <br />SSV + D�/) <br />NAME F OP R TOR <br />l 1 I <br />e <br />ADDRESS�I 5 � oo <br />NEAR CROSS TREET � ^ <br />I� <br />PARCEL (OPTIONAL) <br />CITY NAME <br />STATE <br />IP ODS <br />EX WITHAi AREA E <br />1 <br />A <br />,r/n <br />O <br />�� <br />✓ BOX M CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 0FEDERAL-AGENCY' <br />TO INDICATE <br />7C DISTRICTS' <br />It owner of UST is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS l��i 1 GAS STATION 0 2 DISTRIBUTOR <br />✓ IF INDIAN <br />9 OF TANKS AT SITE <br />E. P. A. I. D. 4 (optional) <br />�4 <br />3 FARM 0 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />?. <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PH E #WITH AREA CODE <br />aVj r o <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />e owe Lr:M6 t:_�- 128 <br />NIG TS: NAME (LAST, FIRST) P NE # WITH AREA CODE <br />G b - <br />NIG TS: NAME (LAST, FI ST) PHONE # WITH AREA CODE <br />2u��vhe C 210 -� <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME_ I / <br />G � a� /l�C//) a,►� <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS G f.�- <br />R �j <br />✓ box to indicate INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />13 O O J iT00 <br />CORPORATION PARTNERSHIP <br />X <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CIN NAME (�/ �l� <br />CIO V1 <br />STATS <br />ZIP COPE _ <br />P ONE�x WITH AREA CODS <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER 'nn <br />I rl <br />OWNER'S TITLEDATE <br />CARE OF ADDRESS INFORMATION <br />!/ <br />MAILING OR STREET ADDREQ <br />G%J <br />%DAY � ' <br />✓ box to indicate = INDIVIDUAL <br />CORPORATION = PARTNERSHIP <br />= LOCAL -AGENCY 0 STATE -AGENCY <br />0 COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY WMEU_ / <br />TAT <br />ZIP COD 2-I <br />PHe210 TL A- CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- - L <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box bindicate �1 SELF-INSURED El 2 GUARANTEE � 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT E:1 6 EXEMPTION 0 99 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: 1. II.X III. <br />THIS FORM HAS BEEN COMPLETEDD� DENY OF P JURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />OWfJEI F'S NAME (PRINTED B SIGNED)� <br />OWNER'S TITLEDATE <br />MO <br />!/ <br />%DAY � ' <br />LOCAL AGENCY USE ONLY / ! / / y <br />COUNTY # JURISDICTION # FACILITY # <br />2il YIK�4_ I I I I I I I <br />b 1� <br />LOCATION CODE - OPTIONAL I CENSUS TRACT # - OPTIONAL I 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 />OWNER MUST FILE THIS FORM WITH THE LOCALL, AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (3/93) FOR003111 <br />