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6N5 [ <br /> C <br /> STATE OF CAUFORMA ��[ <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> yaa�� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY rwi 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CL <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OQERATOR <br /> So t�' -7'EIP-vt 60LIT1ALj_It. <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> X43 S. rj4vk 124>uT6 AZ>A 20 <br /> CITY NAME r r STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> CA A NA7t-AisL.E <br /> ✓ BOX RPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY C <br /> TO INDICATE DISTRICTS' WNfVAC>£NCY' O STATE-AGENCY' FEOEML-AGENCY' <br /> 'U owner of UST Is a public agency,complete the following:name of Supervisor of di isbn,section,or office which operates the UST <br /> TYPE OF BUSINESS 4& t GAS STATION Q 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,Flw�n PHONE#WITH AREA CODE <br /> LIErt rM113 G- �' - II N 171 s'Ic�-4103-Z�I( <br /> NIHTS: NAME( T,FIRST) PHONE#WITHAREA CODE NIGHTS:NAM ( .FIRSTS PHONE#WITH AREA CODE <br /> �Vlvi kv� SIC Cs73 Z'III o 6il� Slb-4103-2111 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME G�f*SND ^ CARE OF ADDRES�Ii'QRMAT�LIN µ <br /> MAI NG'�5O^�R STfl T DRESS L/.�/MI'— ✓ box biMkm �/ =t INDIVIDUAL = LOCAL-AGENCY I� STATE-AGENCY <br /> Mj(.A/ = 9 A�310 W CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDEMLAGENCY <br /> CIT' E STATE ZI CODE PHONE#WITH AREA CODE <br /> v> CAl °14503$ SIO— 4�3-21I� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O.OWNER CARE OF ADDRE SINFO MATION <br /> N > Il� A <br /> MAILING OR STRE TADDRESS �L ✓ OoxbiMkafs INDIVIDUAL E7) LOCAL-AGENCYO STATE-AGENCY <br /> t� moil3�0 CDCORPORATION 0 PARTNERSHIP �COUNTY-AGENCY Q FEDERAL <br /> CITY NAME {] A- ` ST1 CpOD�E--�j�g PHONE#WITH AAREA CODE <br /> 7� <br /> If <br /> IV.Bz2m7 <br /> CCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(V. PMUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bindkafe URED =2 GUARANTEE '®5 INSURANCE Q 4 SURETY BOND <br /> O 5 LMEROFCREgT =6 EXEMPTION 0 97 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: L❑ II.� III.E <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(PRINTED&SIGNED) OWNER'S TITLE DATE MCNTWDAYNEAR <br /> Al iii— M`C 46#'J- • <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> 101 D <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL9UWISOR-DIS2 TRN;T OP77ONAL <br /> loxia 1 <br /> THIS F R9 MUST BE ACCOMPANIED BY AT�(1)OR MORE PERMIT APPLICATION- FORM B,UNLE S IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST -ILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORMA(353) r - "'L � <br />