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SVWI <br /> STATEOFCAUFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILRYlSITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT &5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 98 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /V <br /> DSAARFACILITYE ¢ �5 NAME OF OPERATOR <br /> KESS NEAREST CROSS STREET PARCEL#(OPrC*AL) <br /> fit/ 2rncn 13r�"vim 1-S <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> K� ca <br /> v BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR Q ,/ IF INDIAN #OFT T SITE E.P.A. L D.#(apfimeD <br /> RESERVATION <br /> a 3 FARM O d 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--7 AYS:NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OFAgOFESS INFORM/ATION iA �7 4)w- 1 <br /> MAILI R TREET RESS ✓&oTn NtlkaM/n Q�I ,•NDNO-A'DULL /C3 LOCAL-AGENCYQ STATE-AGENCY <br /> • Dz Q CORPORATION Q PARTNERSHIP Q COUNTY'AGENCY Q FEDERAL AGENCY <br /> CITY NAlff STATSZIP CODE PHONE#WITH AREA CODE <br /> C0 deL4 <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) (//+/�/ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EW 0-*- Q INDIVIDUAL Q LOCAL-AGENCY Q STATE'AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNrY-AGENCY Q FEDERAUAGEWY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ a -- 0 0 0 0 <br /> V. PETROLEUM UST FINANCle RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓yayn 1 SEUNNSURED 0 2 GUARANTEE Q 3 INSURANCE Q I SURETYBOND <br /> S LETTER OF CREDIT Q a EXEMPRON Q 99 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD eE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. B III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY qw4t- JURISDICTION# FACILITY# <br /> �W L/a/D 67 30 F Q I <br /> LOCATION CODE- TONAL CENSUS TRACCT# I� NAL SUPVISOR-OISTMCT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LLEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION bNLY. <br /> FORM A(5-91) FOND=A-5 <br />