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esou�ces STATE OF CALIFORNIA Ar P cO STATE WATER RESOURCES CONTROL BOARD W dam, o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT V 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Ll 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMEev eo — NAME OF OPERATOR A ADDRESS {AJ1�1� NEAREST CROSS STREET (JHPARCEL#(OPTIONAL) 4 4co W XM(.,00 ED, ?I c r.0 L_I 12Z) 101 - 021- 39 CITY NAME 5'I'o��'o STATE ZIP CODE SITE PHONE#WITH AREA CODE CA 95215 2.09- 131- IIE& ✓BOX CORPORATION INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCY' []STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE DISTRICTS 8 owner of UST is a public agency,complete the following name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN j#OFTANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM Q 4 PROCESSOR Q 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) PHONE It WITH AREA CODE 6A5T90 Mlit11; ✓'IL•Vb, �P.�D 'Za1 93l- z18(a NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE GAyfep A,Q419� 1-36'20 -51L-VA; fiAED Pa3artl �✓lU-i 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ct{�,IP.o�I T9vDuc�i s C©. MAILING OR STREET ADDRESS ✓ box to indicate =INDIVIDUAL O LOCAL-AGENCY = STATE-AGENCY fO 13 07C CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE sa NA eAMO(J eA �14$S� 50 842- q 5c-)o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCARE OF ADDRESS INFORMATION C ¢ofd Too a� � PE21m tT pw7I- MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY 1;,o &7� 6m4 54 CORPORATION Q PARTNERSHIP = COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME Gc R�M A ( ST�w ZIP CODE PHONE 11 WITH AREA CODE .—i'► fA N 6!�► 6145$3 2510 842- asoo IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4T4--]-I 0 1 I`l I l V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE E3 4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMP11ON =7 STATE FUND =8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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: I.a It.0 III.2� —1 �pQ1 rttf?'W THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT AME(PRINTED&SIGNATURE) TITLEMONTDAYNEAR N AN l -M �1 AhC�s ML 3bla' CA?-MIA rW 4/3o%I LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY ATL T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLWORAGE TANK REGULATIONS FORM A(6-95)