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F 1L & 0 'eSOVA+�s c STATE OF CALIFORNIA y STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA a . COMPLETE THIS FORM FOR EACH FACILITY/SITE Tunic MARK ONLY ® 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION a 7 PERMANENTLY CLOS ONE ITEM 1:1 2 INTERIM PERMIT F_-] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR L S'To P Cwt PorrT d- IV194 � �3/Zo2f3 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) d-Z Ss E , F2E o _S42t=e-+ II 1; '" StfaraF+ Hl a/y- 03 CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE 64ock-4oni CA 9sa ��O y6v- 16.38 ✓BOX (X CORPORATION 0 INDIVIDUAL = PARTNERSHIP (]LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS 9 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 0 2 DISTRIBUTOR a ✓IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.#(optional) RESERVATION ^� p) �y � Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS ©� G'A�( 0 V6 rj L7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE C>aIcciz. Sla 65 -- e,500 1-A►z.ur.lct ikE CSI ) 6s. - 9-50v NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE aA L(=_P- Ad C PC' ss-I - Se,o IcArzyc t 11 mlv-F- t 51 o) MVO- 0'93Y- 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 0111 t>fu Cam P 4ri rS XIV C_ 12 1 Cl qmj 2u65c i MAILING OR STREET ADDRESS �✓V box to indicate Q INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 6 ox I a6 L!p CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE HufA insorl I SCS 1 b Soy 63- G$D/ Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION It- s ToP 0 5 '�c, Al w MAILING OR STREET ADDRESS �j /� � Sr, boxtoindicate Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY 7,�d 6 F s G / J�CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 0m n'T (fl9lels,3 8 Cs/d) ol5jO--- X560 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-F4--]-101116 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION EM 7 STATE FUND 8 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 99 OTHER V1. 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.❑ It.= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT T NK OW R'S NA E(P INTED&SIGNATURE) �}9raT/=0/4'0WAelL TANK OWNER'S&E !J DATE MONTH>DAYNEAR lei/cam E,G E/�d I`LAGENC USE ONLY .2 j COUNTY# JURISDICTION# FACILITY#C)O((,5`( M 1 ,21 LOCATION CODE - PTIONAL CENSUS TRACT# -OPT/ONA SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIj0ONLY^OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROTORAGE TANK REGULATIONS FORMA(6-95) (� / ✓ C1`��'/�-�r '/` GO-0 19