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0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE Twc Mo.. cno unu unu mme,ry DBAORFA ILITYNAME e vI SC EMERGENCY CONTACT PERSON (SECONDARY) - optional NAME OPERATOR /1 o D u�I%�eL/'P. AD'R31 MARK ONLY F-1 L NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANBLy��// ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE _��1�E�I�1''��I'}'�%''� 7 / 1 0&^11 "W161TO 1k1Ic^n8AAT1^aI 0 APMnP^O IS &I 1^T nl n^Emnl rn 1 CITU NAME DBAORFA ILITYNAME e vI SC EMERGENCY CONTACT PERSON (SECONDARY) - optional NAME OPERATOR /1 o D u�I%�eL/'P. AD'R31 DAYS: NAM ST, FIR T) PHONE a WITH AREA CODE zc74i - S— NE SC S59TREEZ PMCELMIOPFgNAy NIG TS: NAME T. FIRST) -S- MAILING OR STREET ADDRESS SDE__1� ✓ boa blrbkNs INDIVIDUAL CITU NAME ED STATE -AGENCY J- STATE ZIP C / •� SITE PHO�JE WITH�C,O`DF�i-� Q FEDERAL -AGENCY .rte CA � 1lJ `•lf'�/s � J ✓ TO INDICATE RPORATION 0 INDIVIDUAL I� PARTNERSHIP � LOCAL -AGENCY O COUNrYAGENCY' a STATE -AGENCY • D FEDERAL -AGENCY' DISTRICTS' ' X owner of UST Is a public ape , oornplete the following: name of Supervisor of division, section, or oaks which opetates the UST TYPE OF BUSINESSrr t GAS STATION Q 2 DISTRIBUTOR (] ✓ IF INDIAN a OF TANKS AT SITE E. P. A I.D.► Iglatmal) 0 3 FARM 0 4 PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS GMLIKUhNCT UUNIACT PEHSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS -NAM (LAST, FIRST) { /� PH NEa WITH AREA CODE DAYS: NAM ST, FIR T) PHONE a WITH AREA CODE zc74i - S— NIGHTS: NAME (LAST, FIRST( PHONE a WITH AREA CODE NIG TS: NAME T. FIRST) PHONE It WITH AREA CODE 11- PROPFRTY OWNFR INrn PRAATIn KI.IMIICT RF f nMDI CTCn1 NAME 6 /n/ CARE OF ADDRESS INFORMATION MAILING''O7R�STT�REETADDRESS D 6 f r.AS 2v, 11, / a/� — c�L VL /L MAILING OR STREET ADDRESS ' ✓ boa blrbkNs INDIVIDUAL O LOCAL AGENCY ED STATE -AGENCY J- ��f �/Oo-4A-Y ED CORPORATION O PARTNERSHIP O COUNTY,AGENCY Q FEDERAL -AGENCY CITY N E STATE ZIP CODE PHONE a WITH AREA CODE �- X36 6 _ III. TANK OWNER INFORMATION • fMI19T RF (;OMPt FTFn1 NAME OF FOWNER U— / CARE OF ADDRESS INFORMATION MAILING''O7R�STT�REETADDRESS D p''�( ✓ boob kale 0 INDIVIDUAL ED LOCAL -AGENCY 0 STATE -AGENCY / a/� — c�L VL /L ORPoSATION O PARTNERSHIP 11 COUNTY AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD of EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HO 4 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED)— IDENTIFY THE METHODS) USED ✓ bow birdbale O I SELF INSURED 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND O 5 LETTEROFCREDT a EXEMPTION E-1 IN 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. E] II. = III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNERS NAME (PRINTED B SIGNED) OWNERS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY C�O�U�NNTTYY # JURISDICTION • FACILITY III LOCATION CODE-OL4L CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL PT� THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM R. UNLESS THIS IS A CiIANGF OF crit: mmmannu nm v OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (393) • FOR003NA7