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STATE OF CALIFORNIA ' STATE WATER RESOURCES CONTROL BOARD ?a,� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ! , COMPLETE THIS FORM FOR EACH FACILITY/SITE In e ' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR sero.✓ r4C-A2"1^Af` J,NW-7ov TE�ri.vflZ— ADDRESS NEAREST CROSS STREET PARCEL B(OPTIONAL) ' I zf'z W. 5N.11a eogD CITU NAME STATE A ZI .SITE /PHONE Y WITH AREA CODE srv�Ae�✓ J ✓BOX 5jI CORPORATION O INDNIWAL Cl PARTNERSHIP O LOCAL-AGENCY E3 COIINTY.AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS '8ownerd USTk epiLSc agenry,mrry4u 8w loWwn¢caned sigervisord a.6m,sed'Onadliu whitll aperelss Na UST TYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR ❑ REV IF INTION Y OF TANKS AT SITE E.P.A I.D.8(OptimeQ Q 3 FARM ❑ 4 PROCESSOR �K 5 OTHER OR TRUST LINOS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE ' CAR.A1EY Q6E 20 )Va-7001 NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE Bnt✓F.,n- i MEAN Zo9 9PL-S/`f ' II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION STA_eeT4v MAILING OR STREET ADDRESS ✓ CORPORATION PARTNEWDIVIDURSHIP I0 LOCAL-AGENCY O FED STATE-AGENCY ' 1330 I✓OQTH 9dWfDA✓rq)/ CORPORATXIN { PARTNERSHIP COUNTY-AGENCY WITH AREA FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE Y WITH AREA CODE 570u47UW c.4 . 9sao5 Zas III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER ICARE OF ADDRESS INFORMATION 574>C<7441 7EAPJr/NA9t A414 z' MAILING OR STREET ADDRESS ,r./s �y V' axtom8 @ O INDIVIDUALUAL O LOCAL-AGENCY 0 STATEdGENCY 1330 ,VOA-7H 91201 bHCORPORATION I� PAflTNERSHIP Q COUNTYAGENCY FEDERAL-AGENCY NAME STATE ZIP CODE PHONE r WITH AREA CODE CITY :5rvC�7vW �4 9S2o5r �4' ao7 ' IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. TY(TK) HQ 4 4 -L� 17J ' V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box Mkwceta I SELF-INSURED = 2 GUARAMEE Q 3INSURANCE 0 4 SURETYBOND I=5 LETTEROFCREDIT Q 6 EXEMPTION 0 T STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 18 LOCAL GOVT.MECHANISM O 99 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 BILLING: I.❑ It, III.❑ ' THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED 6 SIGNAT ) TANK OWNER'S TITLE DATE MONTHIDAWYEAR LOCA AGENCYU ONLY 6/ A Z31 >2�(� a COUNTY a JURISDICTION a FACILITY a 5_1 1ED FTT=l LOCATION CODE -OPTIONAL CENSUS TRACT 8 •OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL ' THIS FORM MUST BE ACCOMPANIED BYST(1)OR MORE PERMIT APPLICATION- FORM B,UNL THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FO r H THE LOCAL AGENCY IMPLEMENTING THE UNDERGf6D STORAGE TANK REGULATIONS FORM A(6.95) /��L, �)'-i 'i.,J./•�,)