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e6W� P STATE OF CALIFORNIA :�' l' 0 STATE WATER RESOURCES CONTROL BOARD A UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �¢, COMPLETE THIS FORM FOR EACH FACILITYISITE `4��os•`- MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDSITE ONE REM )� 2 INTERIM PERMIT F-14 AMENDED PERMIT E-18 TEMPORARY SITE CLOSURE I. FACILTTYISITE INFORMATION h ADDRESS-(MUST BE COMPLETED) ")RAORFACILTY AAIENAMEOFOPERATOR ADDRESS / NEAREST CROSS STREET PARCEL#(OPfIONAL) CITU NA r 1F}I� STATEZIP SITE PHONE 4 WITH AREA CODE ( CA ,2 O ✓ X CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY (]COUNTY-AGENCY' STATE-AGENCY' =FEDERALAGENCY' TO INDICATE NM DISTRICTS' 'M darner of UST is a public agency,corrplete the Iosowlne:name of Supervisor of division,section,or of ics which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR c7i v' IF INDDIAN *OF TMfL(S AT SITE E.P.A I.D.a(cprimap SER3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUSTLANDS OeJ� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: MET,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box alnacae Q INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY CORPORATION = PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY CITY NAME — -_— STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEPF OWNER „I, ^ -- MAILINOCARE OF ADDRESS INFORMATION eZzu LgJ.BT �9Er1/AS\8 Yl/^// t a o I ✓ boXiosRrals I�a^I'INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY Q CORPORATION PARTNERSHIP CWNTYAGENCY = FEDEML-AGENCY CITYNAME I ST*TFd ZIPpQD l PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916/`))322-9669 if questions arise. TY(TK) HQ F4-14--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓hm bYlasW l�l SELF-INSURED Q 2 GUARANTEE 31NSURANCE 4 SURETY BOND 5 LETTEROFCREDrrEXEMPTION E-1W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IL= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION# FACILITY# ,2 (� ® a33z D s3 LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 UNUNDERGROUND STORAGE TANK REGULA/TIII1O(NIII FORM A(3'63) �� /_—\ J V1 '�. , 1 V `\1\Y/�/VVjakt 01NM '� �� - � P