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`gOVR l' <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD W 4w�' yp v <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLET E THIS FORM FOR EACH FAQL11 TISI I E 4, poR"' <br />MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT F__j 5 CHANGE OF INFORMATION 0 7 PERMANENTLY C <br />ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br />1. FACILITY/511t: INF-UHMA I IUN & AUUHtS, - (MU, I t►t WMYLt 1 tU) <br />DBA OR FACILITY NAME <br />/VIVN1 G 6" Icc C.E�- <br />NA E OF° PERATOR <br />! tbF S coe-jbrJ <br />ADDRESS <br />Lf- 5S 1-t AJ Go �a s <br />NEAREST CROSS STREET <br />C �1 e IG- w r91- <br />PARCEL N (OPTIONAL) <br />CITY NAME <br />�j' b C.jG {ror1 C,* !�20�_ <br />STATE <br />CA <br />ZIP CODE <br />2a <br />SITE PHONE # WITH AREA CODE <br />q ? r <br />✓ BOX l l CORPORATION Q INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' FEDERAL AGENCY' <br />TO INDICATE <br />DISTRICTS' <br />• If owner d UST Is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORRESEIF <br />INDIAN <br />ISOF TANKS AT SITE <br />E.P.A. I. D. # (optional) <br />0 3 FARM 4 PROCESSOR [A5 OTHER <br />R <br />OR TRUST LANDS <br />lcv Iq 6 Z g 1017 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />D YS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />'A -ME Co w- <br />- 4( <br />A4 LM d <br />- l <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NA (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />If PROPFRTV OWNFR INFORMATION - (MUST RE COMPLETED) <br />NAME CI *ry OF cC <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to Indicate 0 INDIVIDUAL <br />LOCAL -AGENCY 0 STATE -AGENCY <br />= CORPORATION = PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME 520 i� <br />� <br />ZIP S'2- v 7, <br />PHONE # WITH AREA CEDE 11 <br />III. TANK UWNEH INFUHMA I IUN - (MU51 lit GUMF'Lt 1 LU) <br />NAME OF QVNER CARE OF ADDRESS INFORMATION <br />v61.1C_ yjb 5 �P r <br />MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL OCAL-AGENCY (] STATE -AGENCY <br />pS A L4/1.I COL Aj "'t Q CORPORATION 0 PARTNERSHIP COUNTY -AGENCY (] FEDERAL -AGENCY <br />CITY NAMEll�S tEp^ '� j O o,1 <br />� STATE 21P �0 _0 �. PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- -1 0I J-1 471 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br />5 LETTER OF CREDIT 6 EXEMPTION 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 ch <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. Q it. 111.0 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />��YS, NAM�� I� � SIGNED) OWNER'S TITL+0 V, -,I I (��, E Jt � � DATE �' MONS DAY/YEAR <br />LOCAL AGENCY USE ONLY F'l D a4 3 q .15 <br />COUNTY # JURISDICTION # FACILITY # <br />[tel <br />LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE • t7P110AUL Af <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE w-OWATION `ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (3193) 0 FOR0033A-R7 <br />