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• 1�-BOY° STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ° UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ue COMPLETE THIS FORM FOR EACH ILITYIStTE MARK ONLY I7 I NEW PERMIT F-1 3 RENEWAL PERMIT 171�5 CHANGE OF INFORMATION 1 ] T PERMANENTLY CLOSED SITE ONE ITEM 7� 2 INTERIM PERMIT Q d AMENDED PERMIT E e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) DBAOR FACILITYNAME '- NAMEOFOPERATOFI � / '1 cai ?'.7 urn Cv- ��lSoi� (tJ .�, �P L, /�/cc �drkS 12261or A ADDRESS _ AREST CROSS STREET PARCEL#(OPMNAL) yyd/ lson !iL✓ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE SID ck�,� CA y o t7 g02 _ - 3100, TO INDICATE Q COR TION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL.AGENCY COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORQ R✓ IESERVATIF INDION AN #OF TANKS AT E E.P.A. I.0.#(optimal) 0 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,ELRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) H ONF 4 WITH AREA COOP II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION u n MAILING OR STREET ADDRESS ✓ boa b kWCaaG Q INDIVIDUAL Q LOCAL-AGENCY Q STATE413ENCY . CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME , `/� Tp ZIPyS 2-O PHONE#WITH AREA CODE III. T NK OWNER INFORMATION•(MUST BE COMPLETED) /V/71 ( NA FOWNER CARE OF ADDRESS INFORMATION //++ Co un -/v /-) Ger/ C��fvrd MAILING OR STREET ADDRESS boa binEbale 4,41 Q ININDIVIDUALVIDUAL QLOCAL-AGENCY Q STATE AGENCY 7, //41 S. CORPORATION Q PARTNERSHIP Q COUNTV-AGENCY Q FEOERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 05 /01:/(-/_0 -z CfJ gsaOS v - vro - o IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ F4-T-4]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa biM9:ak Q I SELF INSURED 0 2 GUARANTEE Q 3 INSURANCE Q#SURETYSOND Q 5 LETTER OF CREDIT =B EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked------., CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ III. ` THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRE APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH DAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTAONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 0 // 3A 3 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5.91) FOR0033A.5 S� �Sv� / • G `� - A