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+ ` c # � � � • gee oa t <br /> STATE OF CALIFORNIA ` o <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> .�� no <br /> � UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �;n , a <br /> off;,. <br /> COMPLETETHIS FORM FOR EACH FACILrTYISITE <br /> FMARK ONLY t NEW PERMIT rL—� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] Z PERMANENTLY CLOSED SITE <br /> �_ONE ITEM ` , 2 INTERIM PERMIT L� 4 AM1.ENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&AD <br /> OPERATOR LAM <br /> E <br /> DBA OR FACILITY NAME � <br /> EV2ON /I CROSS STREET PARCEL#(OPTIONAL) <br /> ADDRESS ' 1\ tVV/III ' 1. -5-riz Arf r <br /> 409 E. /a;n► S <br /> CIN NAME ZIP CODE SITE PHONE#WITH AREA CODE <br /> v <br /> c,kio�+ ivE <br /> I/ BOX Ly7 cORPoRATION INDIV 000UNTY-AGENCY STATE AGENCY FEDERAL-AGENCY <br /> TO INDICATE <br /> TYPE OF BUSINESS GAS STATION I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR O 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) /�V gyZ_ Sto 9s' <br /> pA�\_ ct ann� (SID) 84t- 90$3 A+T�R /L6?T J - <br /> NIGHTS: NAME(LAS .FIRSn HONE#WITH AREA CODE NIGHT : NAME(LAST,FIRST) <br /> GHEvao# r jotS o0 2-11 yAvh� EHONF WITH AREA <br /> II: PROPERTY OWNER INFOR7777la4 <br /> RESS INFORMATION <br /> 'NAME <br /> �fcTZWA�N IVA�^ cate Iqq INDIVIDUAL I� LOCAL-AGENCY IfE <br /> MAILING O WSTREET ADDRESS XTION I� PARTNERSHIP I0 COUN YAGENCY CITU NAME ZIP CODE PHONE WITHS ql N - <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> V&ONFA (LU <br /> AIL PAJLCT_S O�N�`I <br /> MAILING DSTREET ADDRESS T <br /> 3✓?w1 wiMicate OINDIVIDUAL LOCAL-AGENCY [7 STATE-AGENCY <br /> _C`CRPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> 4 \S STATE ZIP CODE P ONE#WITH AREA CODE <br /> CITY NAME <br /> SAN PAIN ca 4 Eta-vee y Sid 4Z- ra9� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF INSURED 2 GUARANTEE E:1 3 INSURANCE 4 SURETY BOND <br /> ✓ bov to intlicate '- 99 OTHER <br /> LJ 5 LETr[R OF CREDIT � 6 E%EMPTION CJ <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: l I.❑ II.[--] III. <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 T BSIGNA LURE) APPLICANTS TI TLE y# DATE MONTWDAY/YEAR <br /> C <br /> w• /�fwlpa Q to^j • ��.!CL.� �Ti¢Ew41�v B- Z3�9b <br /> A0.0 (LJCT VAJ <br /> LOCAL AGENCY USE ONLY ®r 1 <br /> COUNTY# JURISDI TI N# FAr <br /> T UN CODE OPTIONAL CENSUS TRACT# OPTIONAL D 0 Y / <br /> LOCA SUPVISOR-DISTRICTC t <br /> THIS�M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORMA(I231) FILE THIS FORM,WITH THE LOC AL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS \I^PORODA R6 <br />