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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W��' Y <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F7 t NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION U 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Aacp 'FAc�\� �` SAb°1 W%Gh-c Et�TeQ �se� <br /> ADDRESS ,,--`` NEARED CROSS STREET P CEL r(OPTIONAL) <br /> 1%b SO • ���SUN W A W S %N(OTO N <br /> CITY NAME STATE ZIP CODE SITE PHO E r WITH AREA CODE <br /> S'( til,vow CA �520S (20q y - bb33 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP (� LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION2 DISTRIBUTOR ✓ IF INDIAN X OF TANKS AT SITE E.P.A. I.D.0(optional) <br /> 0 RESERVATION <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE;r WITH AREA CODE DAYS: NAM (LAST,FIRST) <br /> 1u 6NT �0�64 C �l�-1�b33 �cbwr �wRV-NCe. , 4 <br /> PHONE WITH AREA CODE <br /> Lw <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIR T) lb� v)?.-(03`1 <br /> MaNat 33 Acca 'tnc�� enra�nea 1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> eco 6uo�-' Cv ,x E�1,% S <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 4,O • ��� CORPORATION CI PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE, TH AREA CODE <br /> �R-ces CQa R�r102.-boa$ (_I\; <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNSRcv Qra�vc�cs CADDRESS INFORMATION <br /> � Co � ARE OF <br /> MAILING OR ST ET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> ORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ITH AREA CODE <br /> �0102-(0031 f,t b16- iqA <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ !4__[2(1-I p (� Cr b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box ioindicate I SELF-INSURED 2 GUARANTEE 3 INSURANCE A SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.C II. IIL <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 M NTW AYNEAR <br /> t ,A� 4__ �Nv. i 1ojti Q 1�amuv , '8 20 q� <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOR0033A-5 <br /> zStr4Qu�N �u�\\r aeP,\ t\r.l�eAh'��lvY <br /> S't'vcx,-Cu <br /> 0 1 Cp, . °lS'1-01 <br />