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neroua � STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�e y,OnMn COMPLETE THIS FORM FOR EACHITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR �os5o � ons �n.c, ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) 1 '2 CITY NAME STATE 21P CODE SITE PHONE#WITH AREA CODE Ic CA I 107- _8 L 11 BOX TO INDCATE 0 CORPORATION I] INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY (]COUNTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) 3 FARM 4 PROCESSOR 5 OTHER RESERVATION D ❑ OR TRUST LANDS CPI EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) 1, /O is: So �- ii - g NIGHTS: NAME(LAST.FIRST) PH INE#WITH AREA COM NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION S 4 MAILING OR STREET"'---- box to ndbate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY ]CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY CITY NAME ATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWN[ 1i I NAME OF OWNER IE OF ADDRESS INFORMATION MAILING OR STREET A V II box to Indicate D INDIVIDUAL LOCAL-AGENCY L-1 STATE-AGENCY (JL\ do I CORPORATION I� PARTNERSHIP I] COUNTY-AGENCY O FEDERAL-AGENCY CIN NAME 1 w�' TE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF E rr,, /�D i-Call(916)323-9555 if questions arise. TY(TK) HO 14 ( \V J V. PETROLEUM r-ftts q =TED)—IDENTIFY THEMETHOD(S) USED ✓ Wr to lntltcala �.//,� ' OTEE 0� 99 OTHER NCE D A SURETY BONG'TION 099 OTHEfl VI. LEGAL NOTIF._...._.. js Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE 00x INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAM E(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# 7/q 7� FACILITY# ® ( —LLLJ�IP-1"J LOCATION CODE -7770NAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION LY. FORM A(5-91)