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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD ...... UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A o o COMPLETE THIS FORM FOR EACH FACILI Y/SRE MARK ONLY ❑ 1 NEW PERMIT F' ' ONE REM2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION CLOSED❑ ER d AMENDED PERMIT ❑ T PERMANENTLY CLOSED~- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLET� 6 TEMPORARY SITE CLOSURE DBAOR FACILITY NAME 96&0* # 3756 NAME OF OPERATOR AT ADDRESS /.b Je-eR y /YIeINToSN 13 75 E. Nf6HWRy 8r NEAREST CROSS STREET PARCEL a(OPTONAL) CITY NAME `ffepy 15 . y� STATE ZIPCODE LO GKEFotTCC SITE PHONE A WITH AREA CODE 61 Box CA 523 ;ZV7 1W727 3441+TO INDICATE 1:1 O INDMDUAL �PARTNERSHIP Q LOCAL-AGENCY DISTRICTS COUNTY-AGENCY' l3 STATE-AGENCY- O FEDERAL-AGENCY' Bowerd USTeegiBFeagmoy.ompM.ftfa3 hgre 01SopeMwof&Wm.MjmwdfKe Md apamecthe UST TYPE OF BUSINESS O j GAS STATION O 2 DISTRIBUTOR O ✓IF INDIAN a OF TANKS AT SITE E.P.A. I.D.I1(optbneD Q 3 FARM d PROCESSOR 0 5 OTHER pRRESERTRUSTVIA IDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 0 S OREN 559 583 3577 NIGHTS: NAM (LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE VOIC7s KAREN sey 5F?3 3398 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION v�TRAA+LRz �Nc _ _ JOHN v c MAILING OR STREET ADDRESS �—✓ bbooS to mCrale 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY 525 W. T-{/AD 5r LLO'CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY Q FEDERAL-AGe1CY CITY NAME STATE ZIP CODE PHONE a WRH;A31;2 ffANFoR� GA f3Z30 �j5 8 3 III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Ut--rR A(Z [AIC— JOHN V467— MAILING R6TMAILING OR STREET ADDRESS ✓ buto^diMe O INDMWAL LOCAL-AGENCY STATE-AGDCY 525 tN. r HIRP ST LJ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CRY NAME STATE ZIP CODE PHONE R WITH AREA CODE NANFoR D �A 9 3 230 55 5s3 3235 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4 - a 2 4 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓EOS to iiiGcele 1 SELF-INSURED 0 R GUARANTEE =3 NWRANCE =A SURETY BOND =5 LETTEROFCREDR =6 EXEMPTION =T STATE FUND O8 STATE RIND&CHIEF FINANCIAL OFFICER LEITER 09 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHAMSM O 89 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.❑ 11.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTWDAWYEAR DOUG IYIA55ARO �' PRO1 MGR 11-30 9� LOCAL AGENCY USE ONLY COUNTY k JURISDICTION N FACILITY M m27- �3oV LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUP"SOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS / ,, FORM A(6-95) {, /� 0v �