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�v STATE OF CAUPORMA ` �o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY F--j I NEW PERMIT F 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE' ONE ITEM Q 2 INTERIM PERMIT = 4 AMENDED PERMIT Q B TEMPORARY SITE CLOSURE I I. FACILrrY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM Ede � Q NAMEOFOPERATOR�nOL,.' Corforo4Lo/\ F6(-Wf U os waS-6;kio Rn O ADDRESS �� A NEAREST QR C1 r PMCELAI 1 r> NA CITY NAME �l STATE �Y ZIP CODE 917E PHONE i W rrH AREA CODE V- CA uA ✓ BOX CDRP ORAT10N INDIVIDUAL 0 PARTNERSHIP DISTRICTS' ISTRI TS' Q COUNTY AGENCY' O STATE-AGENCY' I�FEOERALAGENCY' TOIN BOX LOCAL TS' •N caner of UST Is a pWc agency,mn-plate the TolovOng:name of Supervisor of division.section,or onice which operates the UST TYPE OF BUSINESS J RT t GAS STATION Q 2 DISTRIBUTOR RESE RVADIAN a OF TANKS AT SITE E.P.A. 1.D.A(cptbv$ TO(me(,-SSQ 3 FARM Q 4 PROCESSOR Q 6 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 a WITH AREA CODE Ed Is�nv� s/o-2 -2311 �! NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION 1-)e-�ls kir- o f ank !J• A- • AT1L� r 1'�crbo�r MAILING OR STREET ADDRESS �O .1bM� � D INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY lil s v*A-� 5+- 2- —6 f vo r- IJP CORPORATION I1 PARTNERSHIP O COUNTYAGENCY I)FEOERAL#GENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 5aY` vr.nC.1-3c.0 GA- 9y/ 1 -39 -11 o0 111. TANK OWNER INFORMATION-(MUST BE COMPLETED NAMEOFOWNER L CARE OF ADDRESS INFORMAT N UoOC- Lor Dncl- i0 An 1504W. ( (�a�siroY� MAILING OR STREET ADDRESS^-,_ (� 1 L, �✓/EN 11111"" = INDIVIDUAL LOCAL-AGENCY M STATE- AGENCY OLOOC� C,rOW a�w`VOV% YIL�CG SVI'E�-�FDb Lys CORPORATION OPARTNERSWP COUNTY-AGENCY = FEOEMLAGEWY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE San �o�VVYoY. cA4 gyS83 Slo- 2�� -z3+bl IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ [4-[4--]- V. 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓pss byq�y I SELF-INSURED 2 GUARANTEE D 3 INSURANCE 0 4 SURETY BOND D 6 LETTEROFCREOT 6 EXEMPnoN D 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.El ILD III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED)F-D L-S1b� OWNER'S TITLE DATE MONTHIDAYNEAR s,�. 6,t�. C�EaL�T�1s� 5 s 96 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY• po'/,Z(o LOCATION CODE OPTIONAL CENSUS TRACT@ -OPTIONAL 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 INFORMATION Y. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FORDMIIA{O