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��SpUR Pg C� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 , UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w �` COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY CLOSE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE , n 1. FACILITYISITE INFORMATION & ADDRESS - (MUST BE COMPLETED) 21 11 ,1 -f " DRAOR FACILITY NAME NAME OPERATOR SOL,��v C 4US 7.3 -4060 LAY H Rd P C FIEV ILahl AtZ-F H I PN tvC NIGHTS: NAME (LAST, FIRST) ADDRESS NEAREST CROSS STREET PARCEL 0 (OPTIONAL) U N N g v NLE , 1ILIa- 15D L A r N r2-0 P 'RJD . Bass U CITY NAME STATE ZIP CODE C4 SITE PHONE it WITH AREA CODE LAT H R o P. CA. CA 5 33 TOINDIIC TE CORPORATION E] INDIVIDUAL F7PARTNERSHIP 71 LOCAL -AGENCY COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 4 OF TANKS AT SITE E. P. A. I. D. it (optional) RESERVATION 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE WITH AREACODE DAYS: NAME (LAST, FIRST) SOL,��v C 4US 7.3 -4060 ✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY CORPORATION PARTNERSHIP (] COUNTY -AGENCY 0 FEDERAL -AGENCY NIGHTS: NAME (LAST, FIRST} PHONE # WITH AREA CODE "W -237-90y4PHONE NIGHTS: NAME (LAST, FIRST) L_T/\iv I ,_SiwAD 0 WITH II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME 4�A tz-r H I a r'.l .=� c . CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS�' ;7 qOLu C ER nIE LJh - S -FE- -33 ✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY CORPORATION PARTNERSHIP (] COUNTY -AGENCY 0 FEDERAL -AGENCY CITY N Li N IN1 W Vr 1 -\LJ_—: r CA - STATE ZIP CODE PHONE q WITH AREA CODE STATE Ill. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER 1P A ZT V-1 I ,--\ N .= N1 C... CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box vindicate INDIVIDUAL 0 LOCAL -AGENCY © STATE -AGENCY / qL) L u [ E z )may c— = CORPORATION PARTNERSHIP Ej] COUNTY -AGENCY FEDERAL -AGENCY CITY NAM", STATE ZIP CODE PHONE #WITH AREA CODE U N N g v NLE , CA Bass U IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HQ [4R] - 10 13161 V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED ✓ box tc Indicate 1 SELF-INSURED 0 2 GUARANTEE =1 3 INSURANCE = 4 SURETY BONN 5 LETTER CF CREDIT [_1X 6 EXEMPTION % OTHER S'rATE C t FNM- i.) P FLt 1 D VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I, Q I. 5? Ill. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT NPPLICANT'S NAME (PRINTED S SIGNATURE) APPLICANT'S TITLE DATE MONTH/ AYNEAR ) ,A �A ja�v�-, PC-, St 1-� [PR 5 I Int Int T :!3z 7/ q 5 LOCAL AGENCY USE ONLY Ca# ''`• i�nC 397 3 JURISDICTION# FACILITY# m o LOCATION CODE - OPTIONAL CENSUS TRACT z -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 INFORMATIbN ONLY FORM A (5-91) FOR0033A-5