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(�1�c�5a338`� STATE OF CAUFORNW STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE m o MARK ONLY D�-I NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED.SITE ONE ITEM F-1 2 INTERIM PERMIT Q a AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) px-9 6�3 —3 DBA OR FACILITY NAME ,, // ^) —i --� NAME OF OPERATOR V Cj '`� / Z'e / ADDRESS ^ - 9S� NEAR�CROEETPARCELIlOPf10NW CITY NAME v`/` - /(AJ STATE `•/JIIP CO'-VAI SITE PHONE N WITH AREA-CODE J\ !/ CA � G!i Z � - ✓BOX C�ACORPORATON Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY• 0 STATE-AGENCY• Q FEDERAL-AGENCY• TO IIOICATE DISTRICTS 199AMT d UST,3&Pk 09YIPY.CMVMM 0M tb,*i IrP9 d IV Am cl dVWM 39d'on a dfo MOdi op9 "6K UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q RESERVATION VIFINDIAN N O/F3A/NK/$/A�,T SHITE E P.A/ /N(o7plim/el)p Q 3 FARM Q 6 PROCESSOR 5 OTHER OR TRUST IANDS / // �-.L/� C- V[/n`j p �� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional [DAYS. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE : NAME(LAL .FI PHONE WR}i AREA CyE NIGHTS: NAME(LASE.FlRST7 PHONE k WITH AREA CODE i II. PROPER OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR MEET ADDRESS ✓ Wxroi�dml9 Q WONTDUAL 7=C0=UNTy4GBCy STATEdGENCY �CORPORATON Q PARMEASHIP FEDERAL-AGENCYCRY NAME � ST ZIPONE NWITH AREA CAGE /�C /O� 2 -P III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER -' - - CARE OF ADDRESS INFORMATION MAILING ORADDRESS ) ✓'baaro ildW9 Q INDIVIDUAL Q LOCM.AGENCY Q STATEAGENCY T) ®l/. L"i/J4 JO ORATKkI Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CRY NAMESTA ZIP CODE PHONE t WITH AREA CGDE 510 2— Z•1 y3 So IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Emroi�9 0 1 SEj-MRED Q 2 GUAIUMEE 3 RMWICE Q A SURETY BOND Q 5 LETTER OF CREDIT Q 6 DEMPDON O 7 STATE RIND O e STATE FUND B CHIEF FBWJCVL OFFICER LER ER 09STATE RIND&CERTIRCATEOFDEPOSIT 010 LOCALGOVT.MECHANISM Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BIW NG: I.F] 11 ]� III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTHIOAYNEAR ItIA7N alt M 12 - 02—C7 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N FACILITY M m LOCATION CODE -OPTIONAL CENSUS TRACT N -OP77ONAL SUPWSOR-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 INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS