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'�so�nca c STATE OF CALIFORNIA r °1 STATE WATER RESOURCES CONTROL BOARD W �� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "s � o COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) '(1111�1 IRQ/�/f� nFACILITY ME�� 0n J�775- d+-C�fOR ADDRESS le. Ln. NEAREST CROSS STREET j_Ce- PARCEL # (OPTIONAL) 301 VJ. m ronMal��enahce� 800433-3 ? CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE Lo CAI qPi.2.4n9 -14 ✓ BOX CORPORATION 0 INDIVIDUAL E-1 PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY' STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS ' It owner of UST is a public agency, complete the following name of supervisor of division, sedan or office which operates the UST TYPE OF BUSINESS�1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) 3 FARM O 4 PROCESSOR O 5 OTHER RESERVATION T OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE =� YS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ggQBcE o 2_cq-3W- I'; ronMal��enahce� 800433-3 ? NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE It WITH AREA CODE 6pre rrm o - 231-v6Z3 II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAMECARE fon OF ADDRESS INFORMATION ZVe.r n V. I l MAILING OR STREET ADDRESS PI ✓ box to indicate = INDIVIDUAL ✓ box to inate 0 INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY dicCORPORATION 0 FEDERAL O W eS n G J1 S 1 r' c L� � 0 PARTNERSHIP 0 COUNTY -AGENCY -AGENCY CITY NCE STATE CA3 ZIP CODE STATE /� ZIP CODE PHONE # WITH AREA CODE PHONE # WITH AREA CODE 1 - - 9 - L 1 rf ❑I TANK nWNFR INFnRMATION - (MUST BE COMPLETED) NAqEiOF OWNER Com AD CADRESS NF TION e_✓lro n rod uc s pa rn 1 MAIPG OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CIN N E' �0-rnayl, STATE CA3 ZIP CODE PHONE # WITH AREA CODE 1 - - 9 - ar, IV. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ M44- - 3 I -9 I V. PETROLEUM ST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED Fb,, to indicate 1 SELF-INSURED F7 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND 0 8 STATE FUND S CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT O 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. ❑ 11. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT COUNTY # JURISDICTION # FACILITY # 3'113 'A So-(/.*-, LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL r n THIS FORM MUST BE ACCOMPANIED BY AT' T (1) OR MORE PERMIT APPLICATION - FORM B, UNLES' 5 15 A CHANUE uF 511 t INFuHmA I IuN UNLT. OWNER MUST FILE THIS FORM,_ H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROL. -STORAGE TANK REGULATIONS FORM A (6-95)