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STATE OF CALIFORNIA <br /> b^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A vs <br /> COMPLETE THIS FORM FOR EACt FACILRYISITE <br /> MARK ONLY ❑ a NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [—] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME <br /> �iQo�uG ::7 NAMEOFOPERATOR <br /> ADDRESS <br /> NEARE TCROSS STREET PAACELM(OPrK)NAy <br /> CITY NAME uJ <br /> G� Q STATE ZIP COOED SITE PHONEZ W� AR <br /> C�9 <br /> Ca X5237 7a <br /> ✓ Box <br /> TOINDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY <br /> DISTRICTS D STATE-AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN It OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> ❑ 3 FARM ED4 PROCESSOR OTHER ❑ RESERVATION �p <br /> OR TRUST LANDS v <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> A/Z/dG,Es moo() <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA rnDP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAPE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `` �^ ✓ box bliMkab 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> AI <br /> �W� �� "� /-!•� E::]CORPORATION O PARTNERSHIP I1 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCODE ONE#WITH AREA CODE <br /> Goad Ael� c/A X523 727 5�3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> r e t'Q "r4'co/+2 vt <br /> MAILING OR S1 REE I ADDRESS ✓box bintlbxle INDIVIDUAL 0 LOCAL-AGENCY [:1 STATE-AGENCY <br /> r 24/25- L )J D CORPORATION = PARTNERSHIP O COUNTYAGENCV <br /> CITU NAME - CO FEDERAL-AGENCY <br /> STATE ZIP CODE PONE#WITH AREA CODE <br /> C-4 T, Zc J 727-s�3� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4]-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlbale I SELFINSURED 0 2 GUARANTEE Q 3 INSURANCE ED <br /> O 5 LETTEROFCREDIT =6 EXEMPTION I�59 OTHER 4 SUREN BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> I I Ilk, MC-41-11C12- <br /> LOCATION CGDE -OPTIONAL CE,S3TRACT#�TIONAL SUPVIS�,Oq?�DI,TRICT CODE -OPTIONAL �. � o Y� <br /> THIS ORM MUST BE ACCOMPANIED!_BY.AT LEAST(i)OR MORE PERMIT APPLICATION• FORM B,UNLESS'THIS <br /> , SS IS A CHANGE OF SITEINFORMATIONONLY. <br /> FORMA(5-e1) )YjE <br /> IIT �FORCD33A-5 <br /> • U • <br />