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STATE OF CALIFORNIA + 0 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE ) phi' MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E:] T PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT F-1e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME - NAME OF OPERATOR l p + NEAR STCROSSSTREET I,PAARCERCEL#(OPTIONAL) 5 ADDRESS Z - Zj 0, 3 CITY NAME STATE ZIP ODE SITE PHONE#WITH AREA CODE CA Dlib5 ✓BOX CORPORATION O 1NDMDUAL 0 PARTNERSHIP E:3 LOCAL-AGENCY O COUNTY-AGENCY' ED STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS #oe rot USTbaNbreagewY,GD-Vietethe101kmHg name ol supervisor d#Mukn,Wien ara#ks ehi[h operates the UST V IF INDIAN TYPE OF BUSINESS [_11 GAS STATION ❑ 2 DISTRIBUTOR �( ❑ RESERVATION #OF TANKS AT SITE E/pP./LA 1�Di(optional) ❑ 3 FARM ❑ 4 PROCESSOR [1J 5OTHER ORTRUSTLANDS CAp I_ 00 jj 0 32— EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D S: NAME(LAST, IRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ,� Zo�i- 23 o�ms r1Tl#M.''ICJ �Y;- _5/y3 M__06CPHONE AREA CU1hNI HTS: NAME(LA ST) PHONEp WITH AREA CODE NIGHTS: NAME( ST FIRST) -'O •)Y7�, (�O/,a/�L�� II[II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CAREOFADTSS INFORMATI N YL }ltS _jv o✓v MAILING 5R STREET ADDRESS ✓✓ box to FQlCale INDIVIDUAL LOCAUPGENCV O FEDERAL-AGENCY (�S C )COflPORATION Q PARTNERSHIP ED COUNTY-AGENCY Q FFDEflAL-AGENCY CITY NAME CJ WW STATCA,I ZIP CODE PHONE#WITCOD E0 AREA CE 4/ III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW ER CARE OF ADDRE INFORMATION 1/ t3 S MAILING OR STREET ADDRESS EjrCxto ORATI ED INDIVIDUAL [:ILOCAL-AGENCY � FEDERAGENCY -�/ 6 G W Lyl CORPORATION O PARTNERSHIP (]COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME 6 J STA 21P CODE PHONE#WITH AREA CODE q5� !0104 111 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F474- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Dox to indrate 1 SELF-INSURED ED 2 GUARANTEE 3INSURANCE O 4 SURETY BOND I] 5 LETrEROFCREDR O 6 EXEMPTION 2r T STATE FUND 08 STATE FUND&CHIEF FINANCIALOFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O10LOCAL GOVT.MECHANISM 099 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 ULD BE USY FOR LEGAL NOTIFICATIONS AND BILLING: I.LyJ 11.❑ 111'❑ H FORM HAS BEEN COMPLETED51�' EOF RJURY,AN T TH BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TAN f0M111lRS NAME(PRINTED&SIGNATURE) TANK TITLE DATE MONTWDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# ® `� m=C94 _j LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL I / THIS FORM MUST BE ACCOMPANIED BY ATL (1)OR MORE PERMIT APPLICATION- FORM B,UNLESS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM YWHE LOCAL AGENCY IMPLEMENTING THE IN NDERGROU RAGE TANK REGULATIONS FORM A(6-95)