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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F__1 I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME W NAME OF OPERATOR ►z —P15-19=4Y dAv w 11 6 I C ® 1 Iz I&` '1>t S e /A G. ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 160 1 E 4 0 Sr-,OA IiT F,- CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE l,'b OW-re-c-A CA KS�53 jp 90"'1 - 5-2 ✓BOX 19 CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS I owner of UST is a public a9my,corri;ilels the .name of sWerAsor of divispn,seoiion or of a which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) RESERVATION 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE (~tela—.e U 665 10 Y z ' 77—,6,Le-1&4r,}- 1 -d 7v7 ybZ-ff fr [ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE t L C p 13p�k. �-p $2S�G�Y77N Vt� 7ea7 '(-G-4-X375-- 11. f4 '-X3?II. PROPERTY OWNER INFORMA ON-(MUST' BE COMPLETED) NAME CARE OF ADDRESS INFORMATION w v F• r (' MAILING OR STREET ADDRESS ✓ box to mate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY (47'C AQ Q CORPORATION 9 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE M WITH AREA CODE c�" S4f-SC 2" ?07 4t03-1( 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS be box to irdkate I�INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY ico C (L.. Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE _ LA-Ac z 'I Sot 8 Z1 ?G 7 3 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- - (i► Im IMT- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to Irdlcm Q t SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION STrrATE FUND Q 8 STATE FUND&CHIEF FINANCIAL OFFER LETTER Q 8 STATE FUND d CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 6THER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED F?R LEGAL NOTIFICATIONS AND BILLING: L f-7 11.® 111.O 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'S TITLE DATE MONTWDAYNEAR r— 1z` L144- Z1 ! t LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# L�W t I I I LOCATION CODE-OP77ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUALD STORAGE TANK REGULATIONS FORM A(6.95)