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� • STATE OF CALIFORNIA (COO PY � ,�� STATE WATER RESOURCES CONTROL BOARD u d� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE '& 0 MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILI NAME . 4440q ^^ NAME OF OPERATOR 76 AIDRE OZ N, �� DNL 1K1Y��4�'� r NEA E'S�T CRO$i STREET PARCEL#(OPTIONAL) GJ. O CI OGvtOn STACEA LP E'15 e5+ SITE PHONE#WITH AREA CODE ✓BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0M COUY-AGENUCY'�1 0 STATE-AGENCY' ED FEDERAL-AGENCY' TO INDICATE DISTRICTS Vm vol USTMBpOke9Mxy,wm W,Iheblbw4 n dPMMnlwrd&he n,MiDnadkewhkAo Mos Ne UST TYPE OF BUSINESS F6 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓IF INDIAN N OF TANNKKS�AT SITE E.P.A. I.D.N(Optknal) RESERVATION ❑ 3 FARM ❑ 0 PROCESSOR ❑ 5 OTHER OR TRUST LANDS `J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRP ONE N WITH ARE CODE ST,FIRST) PHONE N WITH AREA CODE (r erso ST) od- Z00 -�5Z I DAYS: NAME(LA NIGHT13: NAME(LAST,FIRS Y] PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Z- Z 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION l e k �jfiore s Inc . MAILING OR STREET AD DRESSn A.L. ,�✓/Loxb^ckNb ��''TQ INDIVIDUAL CD LOCAL-AGENCY Q STATE-AGENCY ✓�©� 1 0<0ORPORATION C3 PARTNERSHIP ED COUNIKAGENCY O FEDERAL.AGENCY CITY pAME STATE P COD PHONE N WITH AREA CODE ROGSnIX 072.-703+ III. TANK OWNER INFORMATION•(MUST BE COMPLETED) N ME OFppDUNE C REOF ADDRESS INF RMATION irGIL� 0r4 �i race 6001`71inaior MAnILIN/G'�OR STREET ADDRESS /j /��T(],.r y✓V bx10Pbi0sle 0NOMDUAL OLOCAL-AGENCY 0STATE-AGE14CY 1 0- ( 040 1 4o•CORPORATION I] PARTNERSHIP 0 COUNTY-AGENCY ED FEDERAL-AGENCY CODE PHO N WITH AREA CODECLent PHONE Tet IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 74T4- _[r7 7 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓box b9NloNe I SELF-INSURED 0 2 GUARANTEE 0 3INSURANCE D e SURETYBOND 0 5 LETIEROFCREDIT 0 9 EXEMPTION 0 7 STATE FUND (] B STATE FUND A CHIEF FINANOALOFRCER LETTER 09 STATE FUND&CERTIFICATEOF DEPOSIT 019 LOCAL GOVT.MECHANISM C::] 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT- TANK ORRECTTANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAVH/E�AR a a.bi2(1i01� aFIML a "e_- -Fpr LOCAL AGENCY USE ONLY CQ-UCQ-UW N JURISDICTION N FACILITY# �. o ! 0 77 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(&95) OWNER MUST FILE THIS FOF !H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR' STORAGE TANK REGULATIONS