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y , • � • � ssoo^ e <br /> STATE OF CALIFORNIA <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �e <br /> COMPLETE THIS FORM F FACILrTY/SITE <br /> MARK ONLY l NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION r _ 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 77 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) �> <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Cgroj o v ..s. A. -9.9- &2 SAME <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAu <br /> 2N001 E- y11ix,,a C,—,REE: F S-raccr <br /> CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE <br /> S LICTOrt _ CA 95.26 ONE <br /> TOINDIC TE D?CORPORATION 0 INDIVIDUAL = PARTNERSHIP E-1 LOCAL-AGENCY E:j COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(optional) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) SIU CJ�t'- U��S <br /> WcA1\,,,,c , Lau"I (Sio� 841- 9093 14„NTe2 2stY <br /> NIGHTS: NAME(LAS FIRSPHONE R WITH AREA CODE NI (LAST,FIRST) <br /> GHEvs�X.T 2od ,�TS G� 800 23!-UIo-z GHT : NAME -5,A PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> ��ERNIgN �x.NRMn+� <br /> MAILING OR STREET ADDRESS ✓ box bIntlbate INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> PC) a 0 X 310 5� CORPORATION (—I PARTNERSHIP COUNTY AGENCY 0 FEDERALAGENCY <br /> CITU NAMnE-x a I r` STS ZIP CODE P ry0i E WITH�� CODE 2,2_00} p0 <br /> 0 1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) L w t G <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> F��V1LoiV R.U1b�G�.S �rN <br /> MAILYG ORQEET ADDRESS box bindbals D INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 <br /> X sOU N CORPORATION 7] PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME SA ZIP CODE ONE A WITH AREA CODE <br /> S y��JAN -09eS042- 89` <br /> s­ <br /> IV. <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_ 4� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate [V<1 SELF INSURED ; 12 GUARANTEE = 3 INSURANCE d SURETY BOND <br /> 17 5 LETTER OF CREDIT =6 EXEMPTION Q 99 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: t.r] It.[--] H.O� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP ANT' NAME IPR T &SIGNATURE) n APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> W. /A"AEQSOa <br /> ARL SU Ms,Tft11_r.ihJ Riair-CT 8 — Z3 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION ff 7 <br /> 3 9 I I Iso <br /> LOGATION CODE OPTIONALiCENSUS TRACT# -OPTIONAL SUPVISOR DISTRICT <br /> 0 3. © of <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE I ORMATIO ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOROD M R6 <br />