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�SCUnCF. <br /> STATE OF CALIFORNIA h ° <br /> STATE WATER RESOURCES CONTROL BOARD Q o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w Q o <br /> n <br /> O� p <br /> CSI IFOP N�. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> im I,Jooi e D 1 C clt- �o A wool o-11 T n <br /> ADDRESS NEAREST CROSS ST ET PARCEL#(OPTIONAL) <br /> 5-01 CvzLe <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ---_—T-,C-a0 0 CA y s zo tv tzn TO INDICATE 5;C CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS [—] 1 GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR 5< 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ` PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) y q$—9 y/Z <br /> /JiCiSot ( <br /> Ili° ` o I g —7/ /? Lancc.-Ster, �1 PHQNF#WITH AREA_CO <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) (Zo y) qy8—5327 <br /> Eli 4 S o►1 m she (Zo 95Z-3ys 0 )i cc.j+t r <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Frah 4RlCkurA Mr_ b'er.IoN wools f <br /> MAILING OR STREET ADDRESS ✓ box ID indicate U INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> /to West C i ej T_ 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> S4oc$_f1 oVt CX cjSLoto (26`1 8- / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERii p CARE OF ADDRESS INFORMATION <br /> Ick" cr hersON (..>00�3 C)11 l_ TMG <br /> MAILIIN/G_OR STREET ADDRESS / ✓ box roindicate 5KINDIVIDUAL LOCAL-AGENCY [� STATE-AGENCY <br /> V �rQ I')kW2S i V G 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY -AGENCY FEDERAL <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE N 4 <br /> 5+-'d I C-A `j'.SZoto (zc1) 9Vg_ /L <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [414'1- <br /> V. <br /> 14 J-V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE R 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION CJ 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.[—] it.E] III.0 <br /> THIS FORM HAS BEEN COMPLETE NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PLICANT'S NAME(PRINTED 8 S�P_;L <br /> GNA ) 1r�{� APPL TS TITLE DATE MONTH/DAYNEAR <br /> a - .>r�u� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY At <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ��C/ 5,��/ FOR0033A-R6 <br />