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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY SED.$ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ p AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA 0 FACILITY N t _ q NAME OF OPERATOR M C r�-t-1 o s CA CY �'I t I EE°''rw� t {'Ny ADDRESS NEAREST CQOSS�S�REET � Lh PARCELr(OPTIONAy 47o -7 a, L- c �tvt^ vk Po_a C-^�" DE CITY NAME S ` I �C k STATE LP CODE J�H !6 7 r W, BOX �COPPORATION 0 INOINWAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY* O STTATE-AGENCY- O FEDERAL-AGENCY ' TO INDICATE DISTRICTS •Nawn DILATE @evuhlic aga oeepWte Me Po9owng:Ibma aSWarvkora&WN,sad wdrm xith ,I the UST ✓IF INDIAN p OF TANKS AT SITE E P.A I.D.It(optional) TYPE OF BUSINESS Ey I GAS STATION Q g DISTRIBUTOR ❑ RESERVATION 7 Q 3 FARM O p PROCESSOR = 5 OTHER OR TRUST LANDS el. EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAB: N�LA E(LA FIRST)FIRST) PHON p WITH AREA CODE- D YS: NAME(LAST.FIRS PHONE p WI rj F}Pt C E 1+1clorTh Jo�n.A 10 51` 76 �s t.rF" va-n 601) zoo - �' �LL NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGMI : NAME(LAST. IRST) PHONE.p WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION NAME -� i Y2f QX MAILING OR STREET ADDRESS ✓ boxk Fb-'b# INDIVIDUAL 0 LOCAUAGEEN 0 STATEAGENCY P O O R 13 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY OFEDERAL-AGENCY CITY NAME STATE ZIP CODE c J PHONE 0 WITH AREA CODE Nk ^#1ewpouj M N i III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER /� _ CA O aglivVSS I<�FORM�103 TOS(-O W f("ih-; t. IMF'U' MAILING OR STREET ADDRESS y S V, boxtofeseate 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY to 0 )( 5 4.Q 4 rvmRPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE phot�t.x A2 SSo1a —��W C714) 418' 65 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- u 3 1- w V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to irK1WQ EY I SELF-INSURED 0 2 GUARANTEE ED3 INSURANCE 0 A SURETYBOND 0 5 LErTEROFCREDIr O e EXEMPTION O]STATE FUND 0 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER 0 8 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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: ED 11.11 111 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED 8SIGNATURE) TANK OWNER'STITLE DATE MONTWDAYYEAR TW^ S-+,rrs LOCAL AGEN Y USE ONLY LITY COUNTY# JURISDICTION# FACIL-J-LJJ--iy—r—/-� LOCATION CODE-OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR•DISTRICT CODE •OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT 1' T(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS—_A IS A CHANGE OF SITE INFORMATION ONLY, OWNER MUST FILE THIS FORM H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU, JORAGE TANK REGULATIONS FORM A(6-95) EH 23 036