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60UF p Pt . 00 STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A n COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY CLOS S ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR -p V�0 L-A 1- S . S Its it g ��-'tom 0 P L.-L_ -- ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S'T 0,.J CA 1S Hca 26-i) 1-I'13-'13 31 ✓ BOX TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ,A MA!A-0o L►-r 1114 1 L4 G-7 2- -1 (o S 9 PHONE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) A rv-kAYb I L-.L l 1 -S -111-1 5'I 2--7 Iv 1i 9 PHONE#WITH AREA CODF II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION lip Qe':�>nvLTs c. - cA6,-- u>JOcam.tr: MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY V-11 2-11 rE- I1Me�—_Y2_4 AL �4 h/ CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE ES iz-1s ej, CA 't z-'I to I9 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION .01 to P2o1r�✓G. alba I,rJ OC-A L- MAILING OR STREET ADDRESS 'p ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY 2L 2q 97. I VL'l r )/�L N y�/ (�CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE >�Z—C- (tea -C--i 2-L,2► � M)14)GnZ- _7L-Gj IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - O o 0 o G V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box toindicate 1 SELF-INSURED it 2 GUARANTEE E::] 3 INSURANCE 4 SURETY BOND O 5 LETTER OF CREDIT =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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.F-1 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR Lv-i� LOQ d)1 t", AD .e,r LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL _ IU I S THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrrE&fbRMATION ONLY. FORM A(5-91) FOR0033A-5