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Doors es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "tee <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 r NEW PERMIT Ej 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLQSE _ <br /> ONE ITEM F-1 2 INTERIM PERMIT [ d AMENDED PERMIT D e TEMPORARY SITE CLOSURE <br /> a <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DGA18P110[ENPACILITY#02479 NAME FOPERATOR <br /> Ian Sisner z - <br /> ADOR'��7 Pacific Ave NEAR%yA 1dET PARCEL#(OPTIONAL) <br /> RiVaFOj <br /> CITY VftktonSTATE ZIP CODE SITE PHONE#WITH AOE&WDE <br /> CA 95207 209-952-4515 <br /> ✓ Box <br /> TO INDICATE CORPORATION E:l INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY STATE AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS [29(l GAS STATION O 2 DISTRIBUTORa RESER✓ IV <br /> AF INTION <br /> DIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM O 4 PgOCESSOR Q 5 OTHER OR TRUST LANDS <br /> CAI QAn 193"g <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY$f1^A1FA(;A$T,FIIRRSRT� PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> JILV LA 1-206-442-7160 <br /> NIGHTS: NA%1-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> BP Emergency Desk 1-800-274-3572 PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMThrifty Oil Company CARE OF A F RtgJS Tl g%Ar ION <br /> CO <br /> MAILING OR STREET ADDRESS ✓ box Polntlkate [:::] INDIVIDUAL O LOCALAGENCY O STATE AGENCY <br /> 10000 Lakewood Blvd CARPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY <br /> CITMEney STATE ZIP CODE PHONE#WITH AREA CODE <br /> LL/J CA 90240 213-923-9876 ! <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NArJEOSCONIVOrthW@St Prop. I, IrIC. CARE OF ADDRESS INFORMATION <br /> II LARRY SILVA <br /> MA�OIG,0138 bUt ET, STE 2500 ✓ box ulntlicate 0 INDIVIDUAL I� LOCAL-AGENCY O STATE AGENCY <br /> VV�I U�V� CORPORATION I= PARTNERSHIP Q COUMY-AGENCY FEDERAL-AGENCY <br /> CIT�NJaI��/HjdF TLE STATE ZIP CODE PHONE It WITH AREA CODE <br /> WA 98101 1- <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4T4] 0 3 6 2 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0Indicate I SELF INSURED 2 GUARANTEE L-1 3 INSURANCE <br /> 1 SURETY BOND <br /> 5 LETTERDFCREDIT <br /> 0 6 EXEMPTION 99 OTHER <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.O II.O kP <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT)( <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> CHESTER BENNETT RETAIL ENGINEER <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> a �S <br /> LOCATION CODE -OPTIONAL CENSUS TRACTA -OPTIONAL SUPVISOfl-DISTRICT CODE -OPT/ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE DFSITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FOR0033A5 <br /> .� s <br />