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eee " e STATE OF CAUFORMA STATE WATER RESOURCES CONTROL BOARD 3e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �"tvan"`n COMPLETE THIS FORM FOR EACH FA ITYISITE MARK ONLY F7 NEW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPOIURY SITE CLOSURE S_} I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 00A OR FACILITY NAME //�` NAME OF OPERATOR Ce.I,-, Y d Y t Gwr SA LL 4, ADDRESS f JINEAREST CROSS STREET PARCEL#(OPTIONAL) 01/ S • 491,tA vva Je S n CITY NAME STATE LP CODE SITE PHONE#WITH AREA CODE SCA �SZoT - S3o TO BOX D CORPORATION O WXVOUAL = PARTNERSMP Q LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGFNCY 0 FEDERALAGENCY DISTRICTS TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR O R SERVATION #OF TANKS AT SITE E.P.A. I.D.s(optinWJ Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional [N'I�GHTS: NAME(UST,FIRST) PHONE s WITH AREA CODE DAYS:NAME(LAST,FIRST) S L2 r / ypq'Yrv6- 3530 NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N W:::::::::�d If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ! CARE OF ADDRESS INFORMATION MAILING OR STREET ADMSS Cm MYtlicw Q RWIVDUAL Q LOCALACFIICY O STATE-AGENCY /L([o C:I CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FFDERALAMKY CIN NAME STATE ZIP CODE PHONE;WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS EPt 0Y4icam INDIVIDUAL QLOCAL-AGENCY QSTATE1GENCY Q CORPORATI(N! O PARTNERSHIP Q COUNTY,AOENCY FIEDERAL,IGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV. BOARD OF EOUAUZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HO F41 74 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ bot nlmicam ED 1 SELFINSURFD Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND =5 LETTER OF CREW O 6 EXEMPTION Q w 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 BILLINQ 1.❑ II.O III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION x FACILFTY s PAClf/Q 3' IX I s 9 0 LOCATION CODE -OPTIONAL CENSUS TRACT-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3J-0 1 3 d 3 4LAd 19 i co THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE WFOR"N ONLY. FORM A(591) ��/ F