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STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> DARK ONLY Q t NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ,E° r <br /> ADDRESS J� NEAREST CRO S/T�RE PARCEL x(OPTgNAI, <br /> viALIC <br /> CITY NAME STATEZIP CODE SITE PHONE i WITH AREA CODE <br /> s� CA -i5z,,D <br /> I/ BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or otlioe which operates the UST <br /> TYPE OF BUSINESS = t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. 1.D.#(optima!) <br /> RESERVATION ) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PRONE#WITH AREA CODE <br /> r,1�z_ t'2n)-zSZ-/Zz <br /> NIGHTS: NAME(LAST,FIRST) P14ONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOFRESSINFO RMATION <br /> MAILING OR STREET ADDRESS ✓ box b VW4418 Q INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> 3>/ v Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY <br /> Q FEDERAL-AGENCY <br /> CITY NAIyIEL/ - � � STATE I ZIC'`PC002 A PHONE 40 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER QQ�� CARE OF ADDRESS INFORMATION <br /> [J" <br /> MMILING OR STREET ADDRESS �1 ✓ bon b Indic" 0 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> K,AN// � J /jLi/h+ 0 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE -7 PHONE i WITH AREA CODE <br /> Go gvv <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)',122-9&9 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE <br /> Q 4 SURETY BOND <br /> 0 5 LETTEROFCREDfT i0 6 EXEMPTION 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: I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED b SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT# JURISDICTION# FACILITY# <br /> LOCAT N CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 =3-60 azo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE UFORMATK)N ONLY. <br /> FORM A(31D3) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> Wi f (�u <br /> •�" i _ FOR0013A-R7 <br /> l � <br />