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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD r , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A sa <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION CK 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIU NAM,t . y J NAME OF OPERATOR <br /> AI 5oz, Ne rl D -�rCrY reZ-TN ESTr $ISTREET PARCEL#(OPDOWIL) <br /> CI o�kfioyn( <br /> STATE ZIP Eq� SITE PHONE N WITH AREA CODE <br /> CA <br /> V,BOX CORPORATION Q INDMDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY' a STATE-AGENCY' O FEDERAL- <br /> AGENCY' <br /> TO INDICATE DISTRICTS <br /> No 0IUSTe8pW1Ce9Mq,mMW8meIb0mha none d srgemwrd@.vbn,ndlcnor0ft vAYA apereHe the UST <br /> TYPE OF BUSINESS 1 GAs STATION Q 2 DISTRIBUTORQ 6'IF INDUW NOF TANKS AT SITE E P.A L D.N(gatimmo <br /> RESERVATION <br /> 0 3 FARM O 6 PROCESSOR Q S OTHER OR TRUST LANDS Lf <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) P ONE N WITH AR CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> er5o &pz_ ZL - 521 <br /> NIG NAME(LAST,FIR PHONE N WITH MEA CODE NIGHTS: NAME(UST,FIRST) PHONE N WITH AREA CODE <br /> t7 �— 2 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CME OF ADDRESS INFORMATION <br /> le k `7inres Inc . <br /> MAILING OR STREET A�/D'DRESS �✓�/Iwxbndnla �INDIVIDUAL �LOCAL-AGENCY 0 STATE-AGENCY <br /> +�. /� �j2Di�' OCCORPORATION =1 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY AMO n n 1 STATE ZjP COD 2--7084' PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) L4J��J�I <br /> EOF WN CRE OF ADDRESS IN RMAT10N <br /> irG eE es Inc. (iosca� m �i2IKe 60Dr21ina1or <br /> MNAI�UNG OR STREET ADDRESS a y✓ xto rdirate Q INDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> r"O• Z ob+ L .CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU AME T STATE ZIP CODE PHONE N WITH MEA CODE <br /> oentX -277-23Iq <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 If questions arise. <br /> TY(TK) HQ F4-F4--]-V3rj5j7M <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ooxbitlicab 1 SDF-WSUREO 0 2 GUARANTEE [1]3 INSURANCE O N SURETY BOND =5 LETIEROFCREDIT 0 N EXEMPTION i=7 STATE FUND <br /> f� 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 0 STATE FUND&CERTIFICATE OF DEPOSIT OIII LOCAL GOVT.MECHANISM 0NNOTHER <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.❑ IL❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> �" a,&vnIA0 of [SIL Qa c -For "fOX(� Ilo <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY N -Q y <br /> O [ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANG OF srrt INFORMATION ONLY. <br /> FORMA(6-96) <br /> OWNER MUST FILE THIS FOR" TH THE LOCALAGENCY IMPLEMENTING THE UNDERGRC STORAGE TANK REGULATIONS <br /> �' l <br />