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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE q' MARK ONLY 1A 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 1:1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR -5 m Cc> Te u C r__ P CA-,,a, 0(_V (_ ry p r f�>�j ADDRESSNEAREST CROSS STREET PARCEL N(OPTIONAL) 10 2-2- FF(Lonrp- c-, p-D. TlACK X10€ a614170 2(.:,! - oz-0 -o¢ CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE RIPoI? CA 9S_3b(=1 2-oq -5-gq-21I I ✓BOX ®CORPORATION L__j INDIVIDUAL W PARTNERSHIP LOCAL-AGENCY ® COUNTY-AGENCY' Q STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE DISTRICTS ' N owner o1 UST is a public agency,complete the following name o1 supervisor of division,seciwn or office which operates the UST TYPE OF BUSINESS Fri 1 I GAS STATION 2 DISTRIBUTOR ✓IF INDIAN a OF TANKS AT SITE E.P.A, I.D.0(optional) i� OR TRUST LANDS GHL ©D O I S6 4-b5- 3 FARM 4 PROCESSOR 5 OTHER EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE rl WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE 61Pswi 71M L. D)NCAti, H I F-um Z"- Sgcf-2 I 2- NIGHTSNAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE 6rIV5aN j TIM L . 2-Cf - -7-> 1- 4511 CAnJ Hoz_um 19. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION CSL M PfA� MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY 2_(�,o N(C 1.4&LLIF Coor_-T =CORPORATION EKPARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE 4 WITH AREA CODE 5tx.TV4 SPTn,) ►J Ct SG o G III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ©L MP(I�N MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY 2—(,'Q m 1 G H. 5L L.E C T Q CORPORATION [PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE S. ,Spj FYL�C(Sco '7+080 80fl-8q{L1-4-45` IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise, TY(TK) HQ 4 4- -10 1 0 2 ¢ q S V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 0 I SELF-INSURED =2 GUARANTEE 0 3 INSURANCE = 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION V<r7 STATE FUND ® 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER [—] 9 STATE FUND 6 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 99 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: L It. III. THIS FORM HAS BEEN COMPLETED U R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SI N URE} TANK OWNERS TITLE / , DATE MONTHIDAYNEAR (�-4- LOCAL AGENCY US NLY COUNTY 0 JURISDICTION N FACILITY k LOCATION CODE -OPTIONAL CENSUS TRACT R -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 UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)