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r.r w STATE OF CAUFORNA ,• STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYiSTTE �.1,. _ ,• MARK ONLY a 1 NEW PERMIT F__j 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION r_� 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT CJ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE F6 I t. rm%-lu I uJl 1 c mrvnmA I IUIV & AUUHE55 - (MUST BE COMPLETED) D81 OR FACILITY NAM A45, el A L-1. NAME OF OPERATOR NIGHTS: NAME (LAST. FIRST) PHONE i WITH AREA CODE ADDRESS Q CORPORATION Q PMTNERSHP Q COUNTY -AGENCY Q FmERAL-AGENCY CITY NAME STATE ZIP CODE PHONE •WITH AREA CODE / NEAREST CROSS STREET PARCEL 0 (OPTOMAU CiTY NAME f STATE ZIP CODE SITE PHONE 0 WITH AREA CODE d CA `� U ✓ Box TOINDtCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCALAGENCY © COUNN-AGENCYQ STATE -AGENCY. Q FEDERAI-AGENCY• N owner d UST is a �fC DISTRICTS' p agency, complete the following: name d Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS Ii GAS STATION <] = 2 DISTRIBUTOR Q s TANKS AT SITE E. P. A. 1. 0. a (gyrk»ap 3 FARM R SEIF RVA��N Q 4 PROCESSOR =5 OTHER OR TRUST LANDS LIAi:nVQil�l WMIAUI rrN` IN IMNIMAMY1 -wn1Aw DAYS: NAME (LAST. FIRST) PHONE s WITH AREA CODE rr-naVn (�C6UrIUAHT)-OpU0n01 DAYS: NAME (LAST, FIRST) PHONE tt WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE i WITH AREA CODE II. FKUPtH I Y OWNER INFnRMATInN . IUI ICT GC f�nuel L -mm NAME VS rAS L CARE OF ADDRESS INFORMATION MAIL NG OR STREET ADDRESS D 7G ✓ box b Nld cm Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY ' � "' Q CORPORATION Q PMTNERSHP Q COUNTY -AGENCY Q FmERAL-AGENCY CITY NAME STATE ZIP CODE PHONE •WITH AREA CODE IV 0AA0f%f%CC 11x11-�rtlnulln�..�...•., rr111l1•I_1\ I.til"1'I\'Ir.rll\`IJ�1�1••��•�elel.`l7.4.f,1.lYM�.Y�-l.l-1 •irl�iy-\ NAME OF OWNER W CARE OF ADDRESS INFORMATION M LING OR STREET ADDRESS ✓ box to rneicros QNDIVIDUAL Q LOCAL -AGENCY IQSTATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATEL 21P CODry�Eh^ �PHONE#w)THAIREA�CODME IV 0AA0f%f%CC 11x11-�rtlnulln�..�...•., - - - - "", vl vllnur_ rcc Ntit.vulY 1 IvuMOCI'i - I all tyib) J2z-9W9 It questions arise. TY (TK) HO 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box t0I11deats Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q S LETTEROFCREO(T Q 6 EXEMPTION Q lag OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked, CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. D 11, 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLEDATE MONTKOAYNEAR I MAI AGCAIf%V IIL1C n1,a v COUNTY # ,)URISDICTION * FACILITY # �0 �-�bb7- LOCATION CODE - OPTIONAL CENSUS TRACT a - OP TOW SUPVISOR. DISTRICT CODE - 0PTXWAL 7-3. 22.-- 3� c> TWS FORM MUST RF u^.t'-nuoA►,ncn OV AT 1 CAOT /.. n� .u...a .. t.r ............. r�wel wrrwlt1 Nm - rvnm o1 UNILLSS H013 tS A CHANGE OF S E WORNATION ONLY. FORM A (3+n3) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE URDERGROUNO STORAGE TANK REGUUjX Nb / FOINI3A`R7 VI