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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ro <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE f ll <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Svu i'h l al I-e—t ven 5tv�e # 1 -117 <br /> ADDRESS NEAREST CROSS STREETI PARCEL#(OPTIONAL) <br /> 2_7Z_'5 CDunfr OQ6) t�kd- z <br /> d <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> cJ�"DGIC�"bp�1'�1 CA q<,- z0+ <br /> Ivy <br /> ✓Box CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 owner of UST is a public agency,corrylete the following name of supervisor of&ision,section or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN 1#OF TANKS AT SITE E P.A. 1.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS 2 r <br /> I J'j V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS PHO #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1� u� q►L �`�7-32�` <br /> NIGHTS: NAM�c�ST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> `J2r(_�t p2v1 C, 7 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NE CARE OF ADDRESS INFORMATION <br /> _5DU�'nl�rtt'� �Ur{ �r��I ah (? rrel`fi <br /> MAILING OR STREET ADDRESS ` ✓ box to kdcate Q INDMDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> -711 CORPORATION =PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE P NE w a CODE <br /> 1x <br /> (�^112s �52�► -o?t� � a6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) -• I3 <br /> N E OF OWNERCARE F ADDRESS I FORMATION <br /> OUTV)nd (' r--'1on 2� r1 ieN.ln►n0 <br /> MAILING OR STREET ADDRESS �✓r,box toix&ate Q NDMDUAL Q LOCAL-AGENCYQ STATE-AGENCY <br /> F <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> C' a1Ya s STATE 7�Z I- 0711P 25>123s`°ZZs <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -10 10 I'Z 12-15 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓box Io kkate Q t SELF-WSURED Q 2 GUARANTEE Q 3 NSURANCE Q 4 SURETY BOND 1P§5 LETTER OF CREDIT Q 6 ExEMPnoN Q 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND b CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.Q 11.Q Ill. / <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TBNK TEF3S NNAMi(PRINTED 3 SIGNATURE) 7kkent <br /> K OWNER'S TILE DATE MONTWDAY/YEAR <br /> I P_1.4L` � Cx � �- <br /> LOCAL AGENCY USE ONLY v J <br /> COUNTY# JURISDICTION# FACIUTY <br /> m FT7 - c <br /> LOCATION CODE .OPTIONAL CENSUS TRACT If -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATk—ST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS.THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORD i THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJ TORAGE TANK REGULATIONS <br /> FORM A(6-95) `1 <br />