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•�aous , c <br />STATEOFCAUFORMA of <br />STATE WATER RESOURCES CONTROL BOARD a <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION --FORM A :mom Y: <br />'p ,t j e' <br />COMPLETE THIS FORM FOR FACHI FAr11 RV/SITE <br />MARK ONLY <br />1 NEW PERMIT <br />3 RENEWAL PERMIT <br />5 CHANGE OF INFORMATION <br />7] <br />7 PERMANENTLY CLOSED SITE, <br />ONE ITEM <br />2 INTERIM PERMIT <br />4 'AMENDED PERMIT <br />6 TEMPORARY SITE CLOSURE <br />CITY NAME <br />CJ 1 <br />I. FACILITY/SITE INFORMATION 81 ADDRFSR - IMI IST RF POIIADI CTDn% <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />AaCo ��C 4132 <br />V\RSotj INN <br />ADDRESS ` <br />NEARESTCROSS STREET <br />PARCEL it (OPTIONAL) <br />O� CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />ceT, �eeVa, <br />STATE ZIP CODEPHONE # ITH AREA CODE <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />STuc\��oN <br />CA <br />gS2UqBOX <br />�2r,A� 41o�.gSt�O <br />TOINDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS ® 1 GAS STATION 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br />I# OF TANKS A7 SITE <br />E. P. A. I. D. # (optimal) <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TgUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) FMFar.FNrV rnNTArT DFDenM icornunaoV, __.1___I <br />DAYS: NAME (LAST, FIRST) _ PHONE # WITH AREA CODE <br />��nJ �1(�SUN C2p�l ,9 -CtS1� <br />DAYS: NAME JLnkST, FIRST) CZUQ� 4� 1p -� �l b <br />1'1RI�t UN �U? l <br />NIGHTS: NAME (LAST, FIRST) PHONE # W TH AREA CODE <br />NI�GetZ CTm ^�v� C2r3q�-�51� <br />NIGHTS: NAME (LAST, FIRST) <br />Y r`�1�, efno $rs0 <br />MAILING OR STREET ADDRESS p <br />�tco c� <br />II. PROPERTY OWNER INFORMATION - (MI IST R1= POnA01 FTGm <br />NAME <br />CARE OF ADDRESS INFORMATION <br />e 1�ro Co_ <br />Ey -6 S <br />MAILING OR STREET ADDRESS p <br />✓ box bindicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />MAILING OR STREET ADDRESS <br />O� CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />�APISs <br />STATE ZIP CODEPHONE # ITH AREA CODE <br />[CORPORATION Q PARTNERSHIP <br />Rc�-1G2��r,3� <br />III. TANK OWNER INFORMATION - (MI IST RF POMPI DTGn% <br />NAME OF OWNER <br />��Zcu Cu <br />CARE OF ADDRESS INFORMATION <br />DATE M NT DAYIYEAR <br />���g� <br />. <br />E 1� t S <br />MAILING OR STREET ADDRESS <br />✓ box ID indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />C) <br />[CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE <br />PHONE # WITH AREA CODE <br />O"102—�003? <br />`t <br />C"1" , 6-l0—NA <br />IV. DUANU ur tUUALICA I IUN Ub 151 UHAGE FEE ACCOUNT NUMBER -Call (916) 323-9555 if questions arise. <br />TY (TK) HD F4 -F4] - d d G 0 (o <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box b indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Cj 4 SURETY BOND <br />S LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br />VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. El II. a III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAMEPRINTED B SIGNATURE) <br />��'1�1,��- Z0.J� �. ���\ ��,f✓ <br />APPLICANTS TITLE <br />ENv. Covhl���(�Ni� <br />DATE M NT DAYIYEAR <br />���g� <br />(Iv <br />i��Y`n�IV <br />LU%oAL AUCNL,T U= UNLT I <br />COUNTY # <br />JURISDICTION # <br />FACILITY # <br />(Iv <br />LOCATION CODE OPTIONAL <br />CENSUS TRACT # - OPTIONAL <br />SUPVISOR - DISTRICT CODE - OPTIONAL <br />J 1 <br />FORMA (5-911)) OIVV 1 VG MVVUIYIrMI\ICU Dt At LCAJI 1,1) Un must FtHM11 AF'ruCAIIUN - f UHM ti, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FOR0033A-5 <br />