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STATE OF CALIFORNIA cyo STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A VtM COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY F__1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C nRPn SITE ONE REM 02 INTERIM PERMIT F-14 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE TIT A I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAOR FACILITY NAME / NAME OF OPERATOR SL V14 77 ADDRESS � NEAREST CROSS STREET PARCEL#(OPFpNAL) ^/ WV CITY KA STATE ZIP CODECA 05 SI�Pl)HO yWIT�AREA CODE 71 I/ BOX LOCAL-AGENCY (p OV TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP DISTRICTS' COUNrY.AGENCY' O STATE-AGENCY' O FEDERAL AGENCY' •U owner of UST is a public agency,complete the follming:nave of Supervisor of dNlsbn.section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(ciolknaq RESERVATION 0 3 FARM 0 4 PROCESSOR 6 OTHER ORTRUSTIANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS- NAME LAS .FIRST) HONE WITH AREA CODE GAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE C�ao9 Fa- 8 NIGHTS: NAME(WT.FIRST) PHON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bladbate I1 INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTYAGENCY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓bmbindirale 0INDIVIDUAL LOCAL-AGENCY E-1 STATEAGENCY CORPORATION O PARTNERSHIP O COUNIYAGENCY FEDEMLAGENCY LE CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EOUALIZATIO FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 a -�'t& rWA,) 136 E '-L V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMkaN O 1 SELF INSURED 2 GUARANTEE [_13 INSURANCE O 4 SURETY BOND O 5 LETTER OF CREDIT 6 ExEMPRON =gb 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.OSI I.D 111.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLYL' 3 D 13 /-A 7 COUNTY p JURISDICTION N FACILITY p LOCATION CODE -OPTIONAL CENSUS TRACT)-W NAL 9UPVISOR-�MICT O� (W710NAC 01 1 3Z 31 \Y7 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3'93) FORD123AR7