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STATE OF CALIFORNIA t �` STATE WATER RESOURCES CONTROL BOARD W ,,,� c UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �, r C�x1�4�M.� 19 , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT rOr 13 RENEWAL PERMIT 5 CHANGE OF INFORMATION O7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT u 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 6/ rnu a • ,norroa _ 1AAI ICT GG t1nRAV I RFT1\ 1. FAVILI1 xIJIIL Inly r.•v�r...-....–�– DBAORFACILITYNAME / MAILING OR STREET ADDRESS NAME OF ERAjOR 62 AL 9 T%Trtt a MS (9rGCPn/ MAILING OR STREET ADDRESS O_!O u ) t.1 ADDRESS Z C' _ f -I A; _ NEAREST CROSS STREET PARCEL#(OPfgNA[) 3 z £. //u STATE ZIP CODE G�ia�i'/o1 CITY NAME Sock STATE ZIPCODE S ONE #WITH AREA CODE/ CA 95Z/S TOIN Box O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 COUNTY -AGENCY STATE -AGENCY (] FEDERALAGENCY DISTRICTSENCY TYPE OF BUSINES 1 GAS STATION 2 DISTRIBUTOR L=j RE/ IF INDIAN AT x OF TANKS AT SITE E. P. A. I. D. # (optional) 3 FARM O 4 PROCESSOR O 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (� ST, FIRST) /� PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) ndonto u[L/x� (zo' 9� 7r 9/ PHONE & WITH AREA MDF NIGHTS: NAME (LAST, FIRST) —�– P ONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE #WITH AREA CODE II. PROPFRTY OWNER INFORMATION -(MUST BE COMPLETED! NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ed O CORPORATION 0 PARTNERSHIP ED COUNTY -AGENCY FEDERAL-AGEWY MAILING OR STREET ADDRESS ✓ boll bkdi:0 E::] INDIVIDUAL [] LOCAL -AGENCY ED STATEAGENCY Z C' _ f -I A; 0 CORPORATION 0 PARTNERSHIP (] COUNINAGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CCOE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER T 4s /'7L CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box binAbalA O INDIVIDUAL 0 LOCAL AGENCY STATE AGENCY O CORPORATION 0 PARTNERSHIP ED COUNTY -AGENCY FEDERAL-AGEWY CITY NAME STATE ZIP CODE PHONE #WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 it questions arise. TY (TK) HO 4X - I—el z- y2 ti Z+,- V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box mintlicale L-1 I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND Ell 5 LETTEROFCREDIT 0 6 EXEMPTION (] W 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. ILO HLE] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED B SIGNATURE) APPLICANTS TITLE DATE , MONTHIDAYNEAR LOCAL AGENCY USE ONLY Jf' COUNTY # JURISDICTION # LOGATIONCODE OPRONAL CENSUSTRACTa-cu'1�. r.n, I SUPVISOR- DISTA1T CODE- OPTIONAL 2 �j0 7 O�l�t A THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS ACHANGEOF SITE INFORMATION ONLY. FORM A (12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS _ - FOROB]]0.A6