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STATE OF CALIFORNIA ,. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> �/ COMPLETE THIS FORM FOR EACH FACILITYISITE NL <br /> MARKONLY ,I�"" NEW PERMIT F7 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE <br /> ONE ITEM (,�L�J 2 INTERIM PERMIT Q s AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM �, NAME OF OPERATOR <br /> �5 Rad <br /> ADDRESS NEAREST CROSS STREET I PARCELI(OPPOW <br /> ('11-Z-32 �1,1472-TlcaO <br /> CRY NAME ^ ST TE ZIP ODE SITE PHONE t WITH AREA CODE <br /> ✓` (((/O O� ` s-2 S 1 209 9-3 0 <br /> ✓BOX O CORPORATIONWOMDuAL O PARTNERSHIP I3 LOCAL-AGENCY O RUNTY-AGENCY* Q STATE-AGENCY• Q FEDERAL-AGENCY• <br /> TOIN)ICATE DISTRICTS <br /> &o al USThIPA)@awvv.=v"PIbb.*W MIMd.upo wd*iwm,XGb9w lk.w ichommuPs UST <br /> TYPE OF BUSINESS CVS�• GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN I OF TANKS AT SITE E.P.A. 1.0.#(01060,181) <br /> RESERVATION / / _ <br /> 0 3 FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS (.-- (..- U 5�' / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS NAME LAST.FIRST) OMOtfJE N WITH AR CODE DAYS: NAME(IAST,FIRST) PHONE N WITH AREA CODE <br /> G r/ f �II.IJ� �z 93 35 �f�170 Zvi L 7_o j 0 <br /> NIGHTS NqfM E�]LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> C <br /> "In <br /> "ef a_-o (v o <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE FAMDRE L_V'I aM <br /> MAILING OR STREET DRESS ✓ 1=10 s INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> SL© Z / O C=CORPORATION O PARTNERSHIP 0 CWNTY-AGENCY l= FEDERAL-AGENCY <br /> CITY NA ST E LP CODE PHONE N WITH AREA CODE <br /> TG C> 7 . 1 9y-11-/ t5 1.O 3 /35 70 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARF�OF ADDRESS INFQRMATO ���,//�D <br /> MAILING OR STREET AD ESSS �/fj[/�� $' ✓ Cole iMFAI MOUAL (]LOCAL-AGENCY O STATE-AGENCY ILC C- 1e04-0 0 CORPORATON = PARTNERSHIP O CWM -AGENCY O FEDERAL-AGEIICY <br /> CITY N ST ZIP CODE PHONE N WITH AREA CODE <br /> 2_ � � 3S�o <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO R-4—1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ea bYN0,1N f� 1 SELF-INSURED Q 2 GUARANTEE JE;-.'L INSURANCE = a SURETY BOND Q 5 LETTER OF CREDIT 0 a EXEMPTION = T STATE FUND <br /> Q B STATE FUND A CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 18 LOCALGOVT.MECHANISM D N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or <br /> 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II. .y IN. <br /> THIS FORMHAS BEEN COMPLETED NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION 0 FACILITY N <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT COOE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(&95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />