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STATE OF CALIFORNIA �` `-✓ A�� ' s <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSE <br /> ONE ITEM O 2 INTERIM PERMIT E::] A AMENDED PERMIT 08 TEMPORARY SITE CLOSURE 9 <br /> I. FACILTTY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N E / �, NAME OF OPERATOR <br /> rAz <br /> AUUHL S `� NEAREST CROSS STREET PARCELA(OPrONAL) <br /> Ile Rd. <br /> CITY NAME` STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> V`J CA <br /> .e Box <br /> TOINDICATE CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' E3 FFDEMLAGENCY' <br /> If owner d UST Is a pubicDISTRICTS' <br /> epency,mrrpMRe the lolowinp:name d Supervbor d tlNkbn,eedbn,W office which operates the UST <br /> TYPE OF BUSINESS 1 GASSTATION 0 2 DISTRIBUTOR ✓ IFINDIAN OOFTANKSATSITE E.P.A. I.1 (gofAVWJ <br /> 3 FARM Q A PROCESSOR 0 5 OTHER O RESERVATION /D <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•aptWw <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODEINIGHLTNMA <br /> DAYS:NAE(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODEME(LAST.FIRST) PHONE•WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Eos bin1lkAm INDIVIDUAL LOCALAGENCY STATE AGENCY <br /> __ O CORPORATION O PARTNERSIIP O COINTYAGENDY O FEDERAL.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bwbWkm INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHP O COUNrYAGENCy D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZ�ATI�ONN LIST 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 /> ✓bot blMkale E-1 1 SELF-INSURED 2 GUARANTEE L-1 3 INSURANCE 1 SURETY BOND <br /> =5 LETTEROFCREOT 6 EXEMPTION Q W 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.= III.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTEDA SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY a3 ?ro <br /> COUNTY 8 JURISDICTION it FACILITY t <br /> s,+„-1f <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -W71ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 31900 <br /> T IS F RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR/M(A/�(I)3931 <br /> /Vv �i' Y( W�• w <br />