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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 ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQ$ED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i ,i 3 I FArII ITV/SITF INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME .11 G� NAM O .OPER yTOR ,DAYS: NAME (LA T, IRST) PHONE # WITH AREA CODE 900 ADDRESS Ic man n. NEAREST CROSS STREET r - PARCEL # (OPTIONAL) CITY NAME STATE Ca ZIP CODE e)5a 4o SITE PHONE #WITH AREA CODE X09-.3 86111 ✓ BOX 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL -AGENCY 0 COUNTY -AGENCY' 0 STATE -AGENCY' 0 FEDERAL -AGENCY' TO INDICATE DISTRICTS ' I owner of UST is a public agency, complete the following name of superAsorol division, section or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) 3 FARM 0 4 PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS CU=r:CtvrV t nNTArT PFRSnN (PRIMARYI EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ,DAYS: NAME (LA T, IRST) PHONE # WITH AREA CODE 900 Q o 0 CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) 'h�vlGn�lPr J.n-�,rmaTlen PHONE # WITH AREA CODE -(;�- Z�)-U(oZ' 0 COUNTY -AGENCY 0 FEDERAL -AGENCY irah� II 0PnPFaTV nWNFR INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to urticate 0 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY Q o 0 CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE lJl/ J m TAAIV nullKIC13 IAICrIORMATInBI . (IUIIST RF rnMPI FTFD) NAME OF OWNER J �CC)rlLA is �'QM _)onk CARE OF ADDRESS INF09MATION MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL D LOCAL -AGENCY 0 STATE -AGENCY lJl/ O CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITYE STATE ZIP CODE J PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE AGGUUN I NUMbt:li - uan ly I of ozz-aooa B q=)LIUI IJ al lot:;- TY(TK) oC.TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box b indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND 0 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 6 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. MECHANISM O 99 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. ❑ It. ❑ 111. Q THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT rANK rOWNER'S NAME (PRINT/ED 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTH/CAYNEAR ".IC. l n ►P%l I AP A! A t`_CAIf%v "Cr- AMI V COUNTY # JURISDICTION # FACILITY It LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL TWIC CnORN UI ICT AP ArmmpANIFn RV AT LF' - (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS IS A CHANGE OF SITE INFORMATION ONLY. ----- - ----- - - - OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU,._ - fORAGE TANK REGULATIONS FORM A (6-95)