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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 <br /> MARK ONLY T NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SRE <br /> ONE ITEM 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NNAME OPERATOR <br /> AME <br /> R o FQC•� �b6 ='� AeitAbe SfyToNs \roc. `SboS <br /> ADDRESS NEAREST CRSS STREET i PARCELS(OPfgNALI <br /> 22S So . C�¢poKe� <br /> CITY NAME STATE ZIP CODESITE PH)E s WITH AREA CODE <br /> CA aS1�o (,I 36s-9301 <br /> ✓ BOX <br /> TOINDCATE CR CR CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTYAGENCY STATE AGENCY FEDEMLAGENCY <br /> DSTRIOTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN i OF TANKS AT SITE E.P.A. L D-•tgmiau)) <br /> RESERVATION <br /> 3 FARM 0 / PROCESSOR = 5 OTHER OR TRUST LANDS 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE`WITH AREA CODE DAYS: NAME(LAST,FIRST) (goo Z'1 Z b3y5 <br /> 1ARr4 (>,1a- oN I (tdi\365 A 1.0 1 k I'^v\VVNANC <br /> NIGHTS: NAME(LAST,FIRST) PH99NEa ITH AREA CODE NIGHTS: NAME(LAST,FIRST) CgOV 2ZZ_b3y <br /> M+�wpzt%es oN DJC l2oq� bS • 30 " " S <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> R 4 L) co . <br /> MAILING OR STREET ADDRESS ✓Om bbtliab = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> P-o • 3q CORPORATION 0 PARTNERSHIP O COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE• ITH AREA CODE <br /> AoaTes. So'1o2-bob-)o- CaaI- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> N.co VrAA 1; Co . BIA-6 S <br /> MAILING OR STREET ADDRESSD ✓ box 0ftK = INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> P. 6 �(/� 03,(�D CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY FEDEIMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> A(i�esi 50ao2-boa (l1y <br /> 6-0-e.40Q <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ baxuinairau 1 SELF INSURED 2 GUARANTEE 1 INSURANCE Q A SURETY BOND <br /> J 5 LETTER OF CREDIT 6 EXEMPTION O W 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.O 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) APPLICANT'S TITLE \ ` DATE MITWIYNEAR <br /> J)&"% rm . ZA �I�, tN-V. O \\CAA AdfA1N Slllol� <br /> LOCAL AGENCY USE ONL <br /> COUmN1TVx JURISDICTIONa FACI�T� <br /> /-ILLS,-rL--ll�/JI r/ <br /> LOCATION CODE OPTIONAL (CENSUS TRACT i -OPTIONAL 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 /> FORM A(5 91) FORA 5 <br /> v <br />