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�✓ STATE OF CALIFORNIA 1'f STATE WATER RESOURCES CONTROL BOARD .•s c++ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A `® COMPLETE THIS FORM FOR EACH FACILITYISITE - ro MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �p[-�Y� 5 CHANGE OF INFORMATION �F��y1 CLOSED ONE REM ❑ 2 INTERIM PERMIT ,{� L� ] PERMANENTLY CLOSED�SITE ❑ 6 AMENDED PERMIT I_J B TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D,1e7�0 FACILI ME- I ADD W G•C 7l;li 3vltt fcL Sf. N REST CRO FEET PARCELN(OPTNk1iL) ti ec�c1v1e CITY NAME I BOX �� STATE ZIP ODE SITE PHONE#Wrril ARFA CODE CA1 (oho > t� S�i9- Zt3( TO✓INDICATE O CORPORATION a womDUAL p PARTNERSHIP I:-LOCAL-AGENCr O TATE-AGENCY FEDERALAGENCY•COUHrY-AGENCYS DISTRICTS •Noenerol USTke RAk N9 q,=M1xe`8r W0-h#rensdSIQNN60re1 Nxckn,sxxlmor otSce whiA apenNs the LIST TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN NOF TANKS AT SITE E.P.A. L D.N(axwlffo ❑ 3 FARM ❑ d PROCESSOR CR 5 OTHER OORTRUSTVATION LANDS I 6�0K Ot9tJ bl4 o�v EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: AE(LAST,FIR T) PHO E N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Za e+r deo Zv�I'� S�t9- 21 t NIGHTS: NAME(LAS 1.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER IfLv� .. . INFORMATION-(MUST BE COMPLETED) { k ` ) CARE OF ADDRESS INFORMATION fel bUA. UtAl ' A 1ISf MAILNOItrUR DRESS 61 kQ WDMWA L GCTAECN I CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY M FEDERAL-AG@ICY CI STATE ZIP CODE ONE N WITH AREA CODE 1 a 4qS1716(o 5-19 213 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NJ OF OWNER / - fj� a e f C i CARE OF ADDRESS INFORMATION MAILINGFOR ,STIREET ESS y� .1 box to itliglN 0 WDMWAL ;W]LOCAL-AGENCY (�STATE-AGENCY 7 .V I QAC t'. e ED CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CIIX NAME' STATEZIP CODE ONE N WITH AREA CODE i t C"4- I f Z7 Sti 9 -u 3 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TIQ HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Em to iMicale 0 1 SELF-INSURED m 2 GUARANTEE [::]3 INSURANCE [::]A SURETY BOND Q 5 LETrEROFCRmIT O 8 EXEMPTION ED 7 STATE FUND O8STATE FUND BCHIEF FINANCIAL OFFICER LETTER 09 STATE FUNDACERTIFICATEOFDEPOSIT El to LOCAL GOVT.MECHANISM O 99 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.O IL.5—a III EJ THIS FORM HAS BEEN COMP UNDEJ PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TMWOWN&M NAME(PRINTED SI ATU T SVIAAlTIT DATE /�N1 Y fc � fY c. Glm 1.1 77-�� /V LOCAL AGENCY USE ONLY R�P�-E•1J COUNTY# JURISDICTION# FACILITY# FTI LOCATION CODE-OPTIONAL CENSUS TRACTN •OPT/LINAC 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 ONLY. OWNER MUST FILE THIS FORM 1-4 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU"'STORAGE TANK REGULATIONS FORM A(8.85)