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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD �y�pB tlao UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A f _ , COMPLETE THIS FORM FOR EACH FACILITY/SITE .ro o MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLY C ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT F6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA 9R FACILITY NAME NAME OF OPERATOR I IR tLkv,L4 ADDRESS to ��/ t / NEST Cfl SSTREET PARCEL#(OPTIONAL) ns CITU NAME STATE ZIP ODE ITE PHONE p WITH AR CODE I CA �5�,66 Zv4�S5q -M63 ✓BOX tl CORPORATION INDIVIDUAL [::]PARTNERSHIP O LOCALAGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS N ownarol USTB a public ageixy,omplete the loeowing:ane of swermord dwision,s%tion oropice which operates the UST TYPE OF BUSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN INOFTANKS AT SITE E.P.A. I.D.#(optional) RESERVATION A NDS e-C 001 Ll" �q 2 ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST CMOS (� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DA NAME(LAST,FIRS I - PHO E p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA Cf Dr r� 7.a Tj S�iq—�43 NIGHTS: NAME(LAS r,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE If. PROPERTY OWNER INFORM ON-(MUST BE COMPLETED) NA '•- II''^^ CARE OF ADDRESS INFORMATION MAILN.G.yy RS EET DRESSC {� ✓ hoe to vldf2le 'SII INDIVIDUAL O LOCALAGENCY I� STATE-AGENCY 2� J S� 3 L CORPORATION ( In PARTNERSHIP Q COUNTY-AGENCY O FEDERAL 2AGENCY CI E STA7,E- ZIPaCODE H,p) p-W, REq COpE.G J III. TANK OWNER INFORMA ON-(MUST BE COMPLETED) C/lam �7Jb "R OWNER L-1i CAREOFADDRESSINFORMATION MAILIN&OR STREET AD ESS ` C .1boxb i�Grste INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY Zvi) L V [::]CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY CI STATE ZIP COIF, - PHONE p WITH AR CODE J IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. J\ o TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SEIF-INSURED 2 GUARANTEE O 31NSURANCE 0 4 SURETY BOND Q s LEREROFCPEDrr Q 6 EXEMPTION ED 7 STATE FUND � 8 STATE Fl1NObOlIEFnNANCIAL OFFICER LETrER O9 STATE RIND b CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM (] 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 AD RESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.❑ THIS FORM HAS BEEN COMPL ED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT T ME(PRINTED B (GNAT ) TANKOWNER'S TIr E- /�, DATE MONTHYDAV/Y CTck"" K Qr rM�TSU Vw me,, �(- -�j LOCAL AGENCY USE ONLY ) dXggra- 7167 COUNTY# JURISDICTION# FACILITY It 10160 ITUS LOCATIONCODE -OPTIONAL CENSUS TRACT# -O IO^NAL SUPVIS04FISTRICT CODE -OPTIONAL V V 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(6-95) OWNER MUST FILE THIS FOR "')i THE LOCAL AGENCY IMPLEMENTING THE UNDERGR01 STORAGE TANK REGULATIONS �°W Oji- 9� q- _Hl W