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STATEOFCALIFORNIA �� 4 STATE WATER RESOURCES CONTROL BOARD NA` - UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , s �• COMPLETE THIS FORM,FOR EACH F LTTYISrTE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT - 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ?J- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Ec2 (- uZPrt N SALES ADDRESS _0 S /^&� NEAfl�TCR�STREET 81tll PPACELt(0PfI0NAL) CITY NAME I /STATE' ZIP CODE SITE PHONE J WITH AREA CODE lf�lcic+n CA n5�.o �< Y�-icl ✓ BOX 5a CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY CD COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL TO INDICATE DISTRICTS' If owner d UST Is a public agency,conplero the IaYowing:name of Supervisor of OHision,section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 RESERVATION/ IF INDDA #OF TANKS AT SITE E.P.A. I.D.#foplional) 3 FARM Q 4 PROCESSOR , 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NI TS: NAME PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE /TZ77tL //o/L6 Fco - �--77� )) T B NAME CARE OF ADDRESS INFORMA N O i 1 �U C �� V1. ( l L v1 , MAIL O T R S I f J biMnm O INDIVIDUAL LOCALAGENCY STATE AGENCY 0124!) .3 CORPORATION = PARTNERSWP COUNTY-AGENCY O FEDERAL CITY NAM ATE ZIP DE PHONE#WITH AREA CODE SS TQa R INFORMATION-(MUST BE COMPLETED) NAy,E OF OWNER CARE OF ADDRESS INFORMATION LCL_77e ,r- AvlQf'i G7� i lc'� z� MAILING OR STREET ADDRESS/ ' Vboib Wr�u INDIVIDUAL O LOCALAGENCY STATE AGENCY LLlq S, V�<��n r, CORPORATION O PAATNERSWP ] COUNTY-AGENCY ] FEDERALAGENCY CITY NAME STATE ZIP ODE PHONE 4 WITH AREA CODE L/4� J�(C)AJ � I a016 IV. BOARD OF EQUALIZATION UST STO AG EE ACCOUNT NUMBER-Cal)(916)322.9669 it questions arise. TY(TK) HQ 4 4- - Z y $ 0 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eos b Imitate Q I SELFINSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND O 5 LETTEROFCREDIT =6 EXEMPTION 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.❑ if.❑ III. THIS FORM HA N MP ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OW SN P D8 ED) OWNER'S TITLE DATE MCNT AYNEAR '-3/:;)5 c5_ LOCAL AGENCY USE ONLY , — T 1 COUNTY# JURISDICTION# FACILITY# �A(1 LOCATION CODE -OPm CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)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(393) • '/y; J� � r