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STATE OF CAUFORNIA 'w STATE WATER RESOURCES CONTROL BOARD '"� o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A >, COMPLETE THIS FORM FOR EACH FACILITYISITE ;� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR v-& 3vS\ , P. RTS ATOS LLC ADORESB NEAREST CROSS STREET PARCEL#(OPTIONAL) -151 Eat S M vc AMo (L CITY NAME ST CA L� 3� E PH �Y WIITH AREA LODE O c 3P ✓Box 59LCORPORATION ED NDMDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' D STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS No cl UST'sapubUcagol y,w 108 %50wkq nsre of Mewsord oHlsm,SectkM Woke a ch operates the UST TYPE OF BUSINESS O I GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN Y OF TANKS AT SITE E P.A I.D.N(optional) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ® 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P ONE Y WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH A EAC E tTz etxra �c� o4 C9Y gc�(o �o�o cA 64 lIL,L `6 .- NIGHTS: NAME(LAST,FIRST)' (� PHO NE Y WITH AREA CODE NIGHTS: NAME(LAST.Fl1R�� PHONEY WITH AREA Ci DE 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) w/LJ p1 SS /� .�p.,� [' /'+ 'C—ARRIE,OF ADDRESS INFORMATION NAM`/{'i�viumV Nsc C) lilJ�s s T+G �_ MAILING OR STREET ADDRESS ✓ bosmsdnle E::] NDNIWAL O LOCAL-AGENCY O STATE-AGENCY '-'ti 1 CAW W y U-) � '��'Q �CORPOMTION [:] PARTNERSHIP (]COUNTY-AGENCY I� FEDERAL-AGENCY CITY NAME � ` STATECADF, J HONE M NTH AREA CODE ZIP O� (11111. TANK OWNER INFORMATION-(MUST BE COMPLETED) -]I 4'�QVfJ. S NAME OF OWNER CARE OF ADDRESS INFORMATION GP.A P�2cso K A OG A'V--5 L- 1--Gc— Cc�(LCst�P MAILING OR STREET ADDRESS ,�1 ✓ bosto Mixte = wDMWAL LOCAL-AGENCY O STATE-AGENCY O C�3—> �61J LAVE �V ;aqdCCORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY GTY NAME STATE ZIP CODE PHONE N VkTH AREA CODE a� e I�rt o rJ CA 3 - IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓boYbY�a O L SELF-NSURED O 2 GUARANTEE O 3 MRANCE I3 4 SURMEMD [:]5 LETTER OF CREDIT 0 8 EXEMPTION L-1 7 STATE FUND O 8 STATE RIND B CHIEF RNANCM OFFICER LETTER =9 STATE FUND B CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O W 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: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJ RY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED a SIGNATURE) by: TANK OWNER'S TITLE DATE MONTHDAYNYEAR Cra4mck�55Dc �s,LLC- LOCAL i' mrwlbe '�— -`7 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# FACILITY#321 LOCATION CODE•OPTIONAL CENSUB TRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 4l'6I�GI THIS FORM MUST BE ACCOMPANIED BY AT LFAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORM , ONN ONV. FORMA(E95) OWNER MUST FILE THIS FOF>�TI H THE LOCAL AGENCY IMPLEMENTING THE UNOERGRI STORAGE TA.JK REGULATION S I D Q i