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STATE OF CALIFORNIA ex oe' STATE WATER RESOURCES CONTROL BOARD .d� e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A se - , COMPLETE THIS FORM FOR EACH FACILITYISITE 'd MARK ONLY ❑ 1 NEW PERMIT ❑ 33 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT Ea<AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME /_'7T C O n I �Q p- NAME OF OPERATOR 191,7_A4 OlfA /A/C ADDRESSI �•Gr{ (v� `0 NEARESTC7S STREET .? I,1 PARCEL I(OPTIONAL) CITY NAME C,5?R�G STATE NZIP CODE 7 I / SITE PHONE N WITH AREA CODE CA ✓BOX / EMIC64PORATION INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY IED COUNTY-AGENCY• STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE - DISTRICTS - '8ownerd UST4apubacagenq.cvirgletelhelolbwngn dsuperviorddW!on,s ionoroNk."Thmemleslhe UST TYPE OF BUSINESS1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESVIFINDIAN ERVATION N OFTAANNKS AT SITE E.P.A. I.D.N(optional) ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS / 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 G i O�N 20y 83 3 235 NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE VArDr, jof4N 20 1 5$ 332 5 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME 0-7-M M p, /Nc. CARE OF ADDRESS INFORMATION JO#N VI+6T Fn MAIUNGORrADDRESSff' D ✓ boxNk 19 L- jIVIDUAL LOCAL-AGENCY OSTATE-AGENCY !�J WW 51T CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAMEN PO f-D STATE � ZIP CODE�Z_ N!f o PHONE NO1 WITH 5;" 32-35 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) / 2 NAME OF OWNER ULTIAMhIRL //YC l, CARE OF ADDRESS INFORMATION Jo /V r46T MAILING OR STREET ADDRESS p box IN Q INDIVIDUAL IED LOCAL-AGENCY STATE-AGENCY 5745 W TwP-D $rr ✓ CORPORATION =)PARTNERSHIP [:3 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODfyyN „ PHONE„-N WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBERC-Call(916)3212%-9669 if questions arise.v/6,)5833 TY(TK) HQ T74 2 4 6 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Em to in0icala 1 SELF-INSURED E3 2 GUARANTEE 0 3INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT E:1 6 EXEMPTION L__1 7 STATEFUND �8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 1 10 LOCAL GOVT.MECHANISM (] 99 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.❑ II.❑ III.E!r _ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE)DD V G Mk S$142D I TANK OWNER'S TITLE DATE MONTHIDAVNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION N FACILITY M m LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLES IS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOE, H THE LOCAL AGENCY IMPLEMENTING THE UNDERGFKWTORAGE TANK REGULATIONS FORM A(6-95) ww -- '�