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STATE OF CAUFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ® e AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA <br /> ��� IDTY NAM F i _* N IME j1 F1YT_&OPERATOR <br /> LGarf h <br /> NEAp�CPOGS ET PAIICAt(OFIIONAL) <br /> i2 Cl Dorado ar l n jrv' <br /> CRY NAME STATE ZIP CODE I YTE PHCt4E•WIDI AREA CODE <br /> 5+06Lion Ca 2oq +�4- -D 1141 <br /> ✓ BOX ®CORPORATION O INDIVIDUAL 0 PAKINEASHIP E::]LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGFNCY' <br /> TO INDICATE DISTRICTS <br /> Eo%rard UST#$a pubo agvq.opnplele the blowing mama d sWenimr of drvisbn,section or d&v ehirh openeaft UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR I = <br /> RESERVATION #OF TANKS AT SITE C/.AD���M5�,4�1 <br /> 3 FARM A PROCESSOR 0 5 OTHER OR TRUST LANDS 3 A <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PM NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> n 1(, -1 <br /> NIGHTS: NAME(LAST.FIRST) RIONE#WITH AREA CODE NIGHTS NAME(LAST.FIRST) PHONE f WITH AREA CODE <br /> ne e, Q n55- 6 <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CME OF ADDRESS INFORMATION <br /> Jr r2i1dl,1 <br /> MAILING OR STRREE,ETMAD,D o ^ ✓q Oozb iidmle O INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> P. SOX 4 W CORPORATION O PARTNEASHP D COUNN AGENCY O FEDERAL-AGENCY <br /> CRY NAry+E STATE LP CODE PHONE#WITH MEA CODE <br /> pY1oenI.x A-Z WIZ,-Zo84 (q I&) ->(aIZ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N�AM�§OF OWNER //,,.�,, ��lJ� CARE OF ADDRESS INFORMATION <br /> T <br /> 1 60 Wr rd'i1QY1 <br /> MAILING OR STREET ADDRESS ✓ Cmlo iidWe Q NDMDUAL EDLOCAL-AGENCY0 STATE-AGENCY <br /> IN <br /> r -0, - q+ lQ@ CORPORATION O PARTNERSHIP Q COUNTY-AGENCY I__1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE f WITH AREA CODE <br /> i'hoeniY, X72- Zo84 (q IG 558 - I&Iz <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eyb' 1 SELF-WSURED O 2 GUARANTEE =3 INSURANCE 0 A SURETYBOND S LETrEROFCRETT Q B EXEMPTION O 7 STATE FUND <br /> EN B STATE NM)&CHIEF FINANCIAL OFFICER LETTER O 3 STATE RIND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 3B 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.❑ II.= In. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK CWNERTS AME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAWYEAR <br /> ? K �T 1✓,;..o fir 'u Tosco I Z/41-17 <br /> K H� ti's �, <x;_ t-3U <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION R FACILITY& <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORT' -H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUWI STORAGE TANK REGULATIONS <br /> FORM A(6-0) <br /> '%vv� 1..0d <br />