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STATE OF CALIFORNIA `w <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILRY/SITE <br />MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT E?5 CHANGE OF INFORMATION D T PERMANENT SED SITE <br />ONE ITEM O p INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br />I FAPII ITV/CITE INICn GApA Inkl e , .. <br />DBAOR FACILITY NAME <br />S4�V0 �rV k <br />ADDRESS <br />N <br />NAAMEME OF OPERATOR <br />? �o,✓a <br />TrUc,lc/,� <br />J�L <br />Lor T/'Ir0 <br />/ <br />NEAREST CROSS STREET <br />P LN(OPrxONpu <br />CITU NAME l <br />a}1�ro <br />oM1 <br />STATE ZIP CODE <br />S TE PHONE #WITH AREA CODE <br />✓ eox <br />TOINDICATE CORPORATION <br />CA <br />Zai 8S??'2S3I <br />I� INDIVIDUAL 0 PARTNERSHIP <br />Q LOCAL -AGENCY Q COUNTY -AGENCY 0 STATE -AGENCY FEDERALAGENCY <br />TYPE OF BUSINESS 0 1 GAS STATION p DISTRIBUTOR <br />DISTRICTS <br />✓ IF INDIAN # OF TANKG AT SITE E. P. A. I. D. # (optional) <br />0 <br />0 3 FARM O 4 PROCESSOR <br />Q— 5 OTHER <br />RESERVATION <br />OR TRUGTLANDS <br />/ <br />----- - I .. --- ...I tmtK�LNUY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) PHONE It WITH AREA CODE DAYS: NAME (LAST, FIRST <br />Lcrta� J 'D C_ C2oq) $58 -25-51 7c,,A e, Jvk'? ci'i5) 86 Y- �YOo <br />NIGHTS: NAME(I AST. FIRST) PHONE#WITH AREA CODE NIGHTS: NA E(LAST, FIRST) <br />EA CODF <br />II. rnvrtn I T UVV NtK IINYVNMA I1UN - MUST BE COMPLETED <br />NAME CARE OF AC7D0 �S INF <br />OR�TI� <br />L. �n�r.er.�s %EV h <br />MAILING <br />ORSTREETAADDDDRRE[SS �y ✓,/Eoa to lMeak INDIVIDUAL 0 LOCAL -AGENCY �' U . """w_ I E? CORPORATION 0 PARTNERSHIP FEDERAL -AGENCY COUNTYAGENCV � FEDEML-AGENCY <br />CITY NAME STA ZIP CODE ,PANE # WITH AREA CODE <br />San Fra�cks v a `I �!// l`7/S� fsb�/- )L/ <br />Do <br />�. vaaL�n mrVnIVI„IIVIN-(NIUAI tatI UMh'LtItU) <br />NAME OF OWNER CARE., ADDRESS INFORMATION <br />L_J INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY <br />CITY NAME CORPGRATION PARTNERSHIP COUNTYAGENCY O FEDERALAGENCY <br />III n„Ann„r­I­ <br />„bwUIN I INumDICK - can (91b) 323-9555 it questions arise. <br />TY (TK) HO 4 4- O Z N O <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED <br />✓ boa blMkala 0 I SELF-INSURED Q 2 §IUARANTEE 0 3 INSURANCE <br />O d SURETY BOND <br />D 5 LETTER OF CREOT EXEMPTION (] 99 OTHER <br />VL LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. O IL u III. O <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS, NAME (PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br />,-vVnV nV L,.V I VJC VIYLI <br />C# JURISDICTION At FACILI g �LS F}L J y <br />LOCATIONCODE OPT�L I CENSUS TRACT# - OPTIIONNAL, SUPVISOR- DISTRICT CODE - OPTIONAL ---- <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, U LE THIS IS A CHANGE OF SITE IN ONLY. <br />FORM A(5-91) <br />FORM3A5 <br />a1 <br />