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u ' <br /> r`4o...... <br /> ;5 C <br /> STATE OF CALIFORNIA A� <br /> STATE WATER RESOURCES CONTROL BOARD W dam, u <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT E]j' 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FACILITY NAME NAM OF OPERATO <br /> evron S+cA+Ion � 93"az Ic-ordo onZaIfS <br /> ADORES S NEAREST CR STREET PARCEL#(OPTIONAL) <br /> 5((0a L.oin/er Sac rckrnenfo t'onto Leon <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> j+o c k +on Ca 95.�to Qo9-477-0947 <br /> ✓BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> It owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS Dy 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA S: NAME(LAST,FIRST) PHONE#WITH AREA CODE D YS: NAME(LAST,FIRST) P NE#WITH AREA CODE <br /> �NZFt�ES (ZIeVogl <br /> D9teVrfn Mnenance. -433-3 <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODEGHTS: NAME LAST,FIRST) PHONE#WITH AREA CODE <br /> l/T,-o ��•§' Pvl�on er rrt �rrrra�ton3Qd•Z31-b(oZ3 <br /> Lj)l <br /> PERTY OWNER INFORMATION-(MUST BE COMPLETED C OF ADDRESS INFORMATION <br /> eras. rshf STREET ADDRE ✓ zlo ndcate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br /> abrn! �Q Dr Q 'ORPORATION [ PARTNERSHIP Q COUNTY-AGENCYFEDERAL-AGENCY <br /> ST E ZIP CODE 7PHONE#WITH AREA CODE <br /> `©c.Jki�vr-� 95�©�Ir <br /> K..OWNER,,INFORMA OMPLETED) <br /> NAMEOFOWNER eAR15 OF ADDRE IN�MATIOY <br /> hevror, t-t3(�UcIS Um an �rrnf IJPJK <br /> MAIL I rORSTREEZADDRESS ,✓�`�oxtondicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 0. <br /> L <br /> r J CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> PHONE#WITH <br /> CODE <br /> ODE <br /> CITY � GA n� v f S T/`� Z C`f GJ•J 10 S�Ae7)AJ©V'°4! <br /> IV.BOARD OF EQUALIZATION UST STORAGE,FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 01 -311 1 <br /> V. PETROLEUM,UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER <br /> VI. 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.❑ II.0 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NA (PRINTED&SIGNATURE TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> ��G�?f l�1clC. L Cfl'1Rfi �53�- rmts:> 1 � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT&T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESM IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORAIM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIWTORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />