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STATE QF CALIFORNIA �• <br /> STATE WATER RESOURCES CONTROL BOARD i��..,•' .'� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICogN- FORM A <br /> COMPLETE T <br /> HIS FORSA.FOREAC FACILITY/SITE eco„a,.,•' <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE DIr4l�qMATON ❑ 7 PERMANENTLY CLOSEDS <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE , p <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME i ME OF OPERATOR <br /> 44q 3 Ma rlvaaa.K <br /> ADDRESS <br /> 205 N EAREST ROSS STREy� PARCEL#(OPTIONAL). etviceAi st C0N14 0- <br /> CI7YNAME STATE ZIP CODE <br /> S ttrcY�'CoiV cAv BOX <br /> 85202 SITE PHON�9`I A. a 3$ <br /> TOINDICATE D CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL AGENCY O COUNTY-AGENCY' O STATE-AGENCY �1 Q FEDERAL AGENCY' <br /> 'A inner d UST Is a Public agency,mrrplete the followin :nan a of Su DISTRICTS' <br /> g pervbor d OHibn,cedbn,W ollim Which OPWrmm the UST <br /> TYPE OF BUSINESS , GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN s OF TANKS AT SITE E.P.A. 1.D.•(apemal) <br /> 3 FARM A PROCESSOR ❑ ti OTHERpSERVATION <br /> R TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON !PRIMARY) EMERGENCTiMMACT PERSON (SECONDARY)-optimal <br /> ENIGHTS: NAME(L <br /> E(LAST,FIRS PHONE•WI H AREA CODE DAYS: NAME(LAST, IRST) PHONE s WITH AREA CODE <br /> v ocY. 146 k OR38 MUc� <br /> T,FIRST) PHONE*WIT AREA CODE NIGHTS: N MA E(LAST,FIRST) P NE a ATH AREA COOS <br /> �i t)C 2o°L��l -6siS8 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME N�(.o rr `b CARE OF ADDRESS INFORMATION <br /> Ea its S <br /> MAILING OR STREET ADDRESS1 p ✓ COYbIItlY 1:1icAINDIVIDUAL 0 LOCAL-AGENCY E:3 STATE-AGENCY <br /> ?'O CAS �Q0 -D CORPORATION PARTNERSHIP =COUNTY AGENCY = FEDERAL-AGENCY <br /> CIT-NAME STATE ZIP I PHONE AITITH AREA CODE <br /> psY2�es gO102-loo3a fit o -S�Fo�I <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Aacb Qro�� Co _ Et1tS S <br /> MAILING OR STREET AOp ESS ✓ Nor biMbaY t INDIVIDUAL O LOCAL AGENCY <br /> Y O = STATE AGENCY <br /> 1 CORPORATION E::] M <br /> PARTNERSHIP 0 COUY#GENCY 0 FEDEML#GENCY <br /> CITY NAME �3R�eT STATE ZIP CODE PHONE*W H AREA CODE <br /> 102—b0 $ DIY '10- SLIn� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eo[bl sm, I SELF)NSURED L-j 2 GUARANTEE (] t INSURANCE <br /> 5 LETTER OF CREDIT 0 A OTHER <br /> 6 EXEMPTION A SUREiY BOND <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: I,❑ II ❑ Ill ®' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWN (PRINTED 6 SIGNED) OWNER'S TITLE ^1 DATE M T AYNEAR <br /> 0Z1Tk <br /> IEA (0 54JN(JL ftw .. q b�q S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY URISDICTKMO FACILITY# tip”— <br /> 7W- 1[-3 <br /> LOCATION CODE .OPTIONAL CENSUS TRACT* -OPTIONAL SUPVWOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERYR App <br /> L)CATioN- FORM B,UNLESS THIS IS A CHANGE OF SITE MA KY <br /> FORM A(M) . <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> -TO', Sos r,-z q\j%I4 to. felt ,Q•C,,_.)X 2ooq S'(x*,Au(\ L<A , (AS -.a 1 TKxumxm <br />