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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ONE REM 2 INTERIM PERMIT ❑ 6 CHANGE OF INFORMATION ❑ PERMANENTLY CLOSED SITE ❑ A AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME S I �+ yAT L� Cl J VE 04 V`I,- O)L TO ADDRESS Y� I C W/1� NEAREST CROSS STREET -J- PAgCELalpprgNAU CITY NAME K IIi' STATE Z�IP+�CODE TE Estill REA CODE ✓Box TTT��yyy CA `i s _ TO INDICATE y�I CORPORATION �INDIVIDUAL 0 PARTNERSHIP LOCA.-AGENCY -N caner d UST Is a public` DISTRICTS• l�COUNfYAGENCY' O STATE-AGENCY' agerlty,waplMe the fallowln :name d S I� FEDERAL-AGENCY B Ipervkor d division.section,m 011;09 whkh cPmmee the UST TYPE OF BUSINESS 1vT i GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D., (optMnaB �❑ 3 FARM ❑ A PROCESSOR = 6 OTHER qR SERRUST LANDS Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-6ptlDnal ;06AYS:NAME(LAST,FIRST) PHONE i WITH AREA CODE YS: E(LAST,FIDS 6 r OIL P E#W TH AREA CODE=NC. Z 9'�8 -�lSNAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) p NE#WITH AREA CODE sV Oil, g $ - 31� \ � IY1 IO J—(o II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS q\ ✓besot top Q INDIVIDUAL = LOCAL AGENCY t1 STATE AGENCY (/ 9b A 5<CORPOMTION O PARTNERSHIP =CCXJMAGENCY O FEGERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C S Slo 7S-(ol//5- Ill. /SIII. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION f)fK MAILING OR STREET ADDRESS ✓ box bkdkm = INDIVIDUAL =LOCAL AGENCY lD STATE-MfRCY Rsno wit-Ln-0 Dm pj�' CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERALAGEWY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE t ^ coftme I) IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. N - 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓hm bbflcalm 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE A SURETYBDND 6 IETtERGFCREDIT 6 EXEMPnON F--1 MOTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or�11 its checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ Il.l yl III.I\X THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'SiPRINTED6 SIGNE WNER'S TITLE Lv�V( DATE MVNEAR kjn LOCAL AGENCY USE ONLY 6 COUNTY# JURISDICTION# FACILITY is m LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FORDD3NA7