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a0 ^'youncC.c STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE t� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSESI ONE ITEM 1:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE q 11 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME S-b NAME OF OPERATOR �o r•A1A OV�e_ Y W� ADDRESSNE REST CROSS STREET PARCEL#(OPTIONAL) .? u . yosem t4e_ A\)e- \Wr ov a CITY NAME STATE ZIP CODE I SITE PHONE#WITH AREA CODE M0r4eco' CA q5337 I ,20q- _139- q5_7.5 ✓BOX Q CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS ® 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.It(optional) RESERVATION / 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS j�l EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY NAME(LAS ,FIRST) PHONE#WITH AREA CODE DAYS: NAME( ST,FIRST) PHONE#WITH AREA CODE cG Zo s of v:,,n Jaln NI TS: NAME(LASr,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE sc.-mc- 2.9 "C'_m 2.601S 113 o II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY -20-7 .-)- W - y0 SQ1n.4-t Ade— [::]CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE t (ALA�eC CA 9533 7 "20 - 23 -9573 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY a0 7 2 'W Yo-rem t e Ave- =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE �aH�rc�L GA 95337 2c)9 - 239 -8575 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED [�] 2 GUARANTEE O 3 INSURANCE E:]4 SURETY BOND = 5 LETTER OF CREDIT Q 6 EXEMPTION E:j 7 STATE FUND =8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND 8 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification 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.% ll.O III-0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#Ooy6a� ❑ [� a 3 y a LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL N t3 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 FORM A(6-95)