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y a STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION u 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA a/�/94�RS• FACT NA ,DS .G NAME OF OPE R N !' /a� a ADDRESS� � ��GEST CUROSS STREET PARCarpPnONYJ -3 L / ulqz CRY NAME STATE CODE SITE PHONE a WITH AREA CODE ,S-fo oyo G , CA ✓ BOX i]ooRPORAnom I] INomoVA L-3PARTNERsIm C:3LOCALAG84CY C:)COUIM-AGENCY• 171 STATE-AGENCY* ERA-AGENCY' TO INDICATE DISTRICTS •uo..wrdusrn.RleeayK..y.�lml�sn.nn.:��aP.d:,n.I.�da�N1.Ma�l�raw.nmoo.alo6nusr TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 01STRISLJTOR RESVIFINDIAN ERVATION a OF TANKS AT SITE E P.A. I.D.a rgM0rW) ❑ 3 FARM ❑ A PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY NAME(UST FIRST) ryPHONE a WITH AREA CODE DAYNAME( ,RRST) PHONE M WITH AREA CODE NIGHTS: NAM 1L .FIRST) PHONE N WITH AREA CODE NI HTSNr(LAST.RAST) � WTtj�AREA CODE IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) 44 3 NAME po c CARE OF ADDRESS INFORMATION J MAILING OR STREET ADDRESS ✓ =W .e i] INDIVIDUAL ] LOCAL-AGENCY ]STATE-AGENCY ]CORPORATION ] PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE I LP CODE PHONE r WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / ✓ SNtNaMole ] NOmom LOCAL-AGENCY STATE AGENCY coFWORATON I] PARTNERSHIP i]COUNTYAGENCY -AGENCY CITY NA EL" G " STATE ZIP CODE PHONE a WITH AREA CODE S•, G - c,4 q�a �9-or3ro , 3 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ, M44- -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED fpGb�e ] i SELF-WSURED ] 2 GUARANTEE ]3 MRANCE ]A MRETYBM i]5 LE TEROFCR®n ]6 ExEMPTON ]7 STATEFUND ] a STATE FUND&CHEF FINANCIAL OFFICER LETTER ED 9 STATE RIND&COMFICATE OF DEPOSIT 0ioLOCAL GoYr.MECHANISM 1:3990TNEN VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 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.❑ 11.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED A SIGNATURE) TANK OWNERS TITLE DATE MONTWDAWYEAR LOCAL AGENCY USE ONLY 3 COUNTY N JURISDICTION• FACILITY k � 101013 LOCATION COBE -OPTIONAL CENSUSTTUCTa -OPDONAL SUPVIBOq-OISRNICT LODE -OPTIONAL ((/' THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL ECA�NCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG LATIONS , 1 -a�m t � su-� - 6- a8—�`r