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r `bOURCft STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i �', c UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W" '.� o COMPLETE THIS FORM FOR EACHCILn YISITE MARK ONLY F-1 I NEW PERMIT r 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM �i 2 INTERIM PERMIT L- a AMENDED PERI 6 TEMPORARY SITE CLOSURE QG I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 6 J DBA OR FACILITY NAME ( (1'_ /� NAME OF OPERATOR {� (A C V(1 C SCa�.J d I K WT ..t S ccJ Si, / EST CROSS STREET I, `uJ� C e �PAR�CEL 0 OPrIONAu ADDRESS �\ J� � < (� CIN NAME ! STATE ZIP CODE SITE PHONE#WITH AREA CODE 12 c.(� CA I/ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY DISTRICTS Q STATE-AGENCY Q FEDERAL AGENCY TYPE OF BUSINESS GI I GAS STATION C 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM Q a PROCESSOR Q 5 OTHER OR TRUST LANDS J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 1)vu Ce-F--fe I a0hvN 0 - 7 V p_&73_5' /-.,4 NIGHTS: NAME(LAST,FIRST) PHONE#WITH-AREA CODE NIGHTS: NAME(LAST,FIRST) PHOME-4 WITH AREA rnnr PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED! NAME„ i CARE OF ADDRESS INFORMATION 011" MAILING OR STREET ADDRESS + I ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 3 't d-' 4-�-GCS' C+��c� u I -1/l . LQ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 54-,7 c-k-4 FA 19 S ave 2_v9- - 3=r�— III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S MAILING OR STREET ADDRESS . ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME !STATE ZIP CODE PHONE#WITH AREA CODE I IV. BOARD QULITESPn S STORAGE FE COUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) H 14 4 I-V. PETROLEUMNSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED ✓ box to indicate Q I SELF-INSURED " 2 GUARANTEE Q 3>BEIRANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION 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 Check . CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.D THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY Z COUNTY# JURISDICTION# FACILITY# CA4 LOCATION CODE -OPTIONAL CENSUS TRACT tt -OP7IGNAC SJPVISOR-DISTRICT -OPTIONAL 0/ 2 2,Yi) 23� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERNIIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ® FOR00.33A-R6 F