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� ® tbovp cs STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Y . a?Q UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE �•� �a�N MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ,� 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE REM a 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) r)RA OR FACILITY NAME S7Z:>,o-0 NAME OF OPERATOR ✓A"we- �` /,��1�/ i<A T7 ADDRESS NEAREST CROSS STREET PARCEL M (OPTIONAL) CITY NAME STATE CA ZIP COD 530BOX SITE PHONE X WITH AREA CODE TOINDICATE O CORPORATION ED INDIVIDUALARTNERSHIP LOCAL -AGENCY 0 COUNTY -AGENCY' O STATE-AGENCYFEDERAL-AGENCY' DISTRICTS' If owner of UST is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS Ej�l' l GAS STATION r__j 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E. P. A. I. D. a (optional) 3 FARM 0 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PFRSON im nNnARvi - . ti ...i DAYS: NAME (LAST, FIRST) PHONE ii WITH AREA CODE K� 404)8�3.4osl DAYS:.NAME (LAST, FIRST) PHONE * WITH AREA CODE �.4Q 1 1-49Z AT zvq �a -4 r� r NIGHTS: NAME (LAST, FIRST) PHONE * WITH AREA CODE '.7 �W'C4"Cj��(4r-)q832-4694.3 NIGHTS: NAME (LAST, FIRST) PHONE WITH AREA CODE A .�,�- II. PROPERTY OWNER INFORMATION - (MAST RF CnMPI FTFn1 NAME / �/Q� Ct4.2Ac� Z A 25,fir—, CARE OF ADDRESS INFORMATION �,o �,�.00z.9 MAILING OR ATREET ADDREEESS/ o O ✓ box b indicate = INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY • . /c7 (J f Ca CORPORATION = PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY i CITY NAME � n STATS ZIP CO�� PHONE ll WITH AA,0;-4141 � DE 4`4 / III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER 12 ,Qp ZA &1-17-- CARE OF ADDRESS INFORM. TION ,15:-,o Z/ MAILING OR STREETADDRESS J v 0 2 Z ✓ box b indicate = INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY 00. - �/ OX / YEZORPORATION = PARTNERSHIP E=1 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME M tir�z ST E � ZIP CODE 9.3,3-3 PHONE N WITH AREA CODE 1 � IV. BOAHU OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HO F414 --l-1614 q V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box b indicate 1 SELF-INSURED a 2 GUARANTEE = 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION = 99 OTHER A. 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. = II. [-1 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLE A , I DATE MONTWDAYNEAR 7 i9/L c';0•�� Is; LU(:AL AUtNGY U5E ONLY COUNTY # JURISDICTION # FACILITY # m LOCATION CODE -OPTIONAL CENSUS TRACT s - OPTIONAL SUPVISOR - DISTRICT CODE -OPTIONAL 1111115 rUnM Mus) BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION -FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMAN ONLY. OWNER MUST FILE THIS FORM W THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN STORAGE TANK REGULATKW � � FORM A ("3) �I