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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W�d� moo UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e, _ COMPLETE THIS FORM FOR EACH FACILITY/SITE 'MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS �4 ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ B TEMPORARY SITE CLOSURE 1 CAf-I ITVIQITF IAIPnRMATInhl R AnnRFss - (MUST BE COMPLETED) CJ / DBA OR FACILITY_ NAME - r Sv ER NAME OF OPE ARE C -f /V Je co 4 v mi DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 4S-GS9/ ADDRESS 9 2 a th ro d. NE RESTCROSSSTRSET PARCEL#(OPTIONAL) CITY NAME Q rva STATE CA ZIP CODW I I SITE PHONE #WITH AREA CODE N-1Vet ✓ BOX CORPORATION O INDIVIDUAL a PARTNERSHIP 0 LOCAL -AGENCY O CDUNTY-AGENCY' CD STATE -AGENCY' O FEDERAL -AGENCY' TO INDICATE DISTRICTS ' X ownarof UST a a public agency. omWlete the following: name of swermorol dwivbn. sadiron or otF= which operates the UST TYPE OF BUSINESS X 1 GASSTATION=] 2 DISTRIBUTOR ❑ 3 FARM ❑ 4 PROCESSOR Q 5 OTHER O ✓ IF INDIAN RESERVATION OR TRUST LANDS # OF TANKS AT SITE E. P. A. I. D. # (optional) DD^Mk1rV PMkTTAPT DCD0nM IDOIMGDVI FMFRRFNCY CONTACT PERSON (SECONDARYI • ootional DAYS: NAME (LAST. FIRS PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 4S-GS9/ %7-745- MAILING OR STREET ADDRESS o 11.! rTotiN NI HTS: NAME (LAST, J OPA/6'(llt/FITr)hw 7o7E74S # WITH -669 EA CODE / [E NAME (LAST, FIRST) NIGOSGOE IVEO REA CODE PHONE 8 WITH -669/ 0-74SS: N_ PROPFRTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION FACILITY # 1510151 F C11.1f&/I Ae CO CENSUS TRACT# -OPTIONAL MAILING OR STREET ADDRESS .1 box to rxi 0INDMDUAL O LOCAL -AGENCY STATE -AGENCY P0 �U X O (� p O 6 IJ CORPORATION O PARTNERSHIP Q COUNTY -AGENCY I3 FEDERAL -AGENCY CITY N E �t-hi-�:- STATE Ca. ZIP CODE 9ySlo PHONE # WITH AREA CODE 707-7/5-669/ J �1 IB TANIIY nWMFR INIFnRMATIOH-IMIICT RF (.OMPLFTEDI NAME OF OWNER !f__ CARE OF ADDRESS INFORMATION I0 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 it questions arise. TY (TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED ✓ box to indcate 0 1 SELF-INSURED 0 2 GUARANTEE Il 3 INSURANCE E::] 4 SUREYBOND [::15 LETTEROFCREDTr Q S EXEMPTION 229 7 STATE FUND OBSTATE FUND ACHIEF FINANCIAL OFFICER LETTER 09 STATE FUND& CERTIFICATE OF DEPOSIT C:1 10 LOCAL GOVT. MECHANISM I199OTHER 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. ❑ II. ® 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT COUNTY # FT -1 JURISDICTION # FT7 FACILITY # 1510151 F VSUM EK W CENSUS TRACT# -OPTIONAL MAILING OR STREET ADDRESS v' box loindioote Q INDIVIDUAL D LOCAL -AGENCY O STATE -AGENCY D /J O X 8 6 291 CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME R6N/r,/ a STATE '' ZIP CODE 9tiSlo PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 it questions arise. TY (TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED ✓ box to indcate 0 1 SELF-INSURED 0 2 GUARANTEE Il 3 INSURANCE E::] 4 SUREYBOND [::15 LETTEROFCREDTr Q S EXEMPTION 229 7 STATE FUND OBSTATE FUND ACHIEF FINANCIAL OFFICER LETTER 09 STATE FUND& CERTIFICATE OF DEPOSIT C:1 10 LOCAL GOVT. MECHANISM I199OTHER 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. ❑ II. ® 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT COUNTY # FT -1 JURISDICTION # FT7 FACILITY # 1510151 F LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLIUAIIUN - YUHM D, UNLCaa rnio is H �' - -I OWNER MUST FILE THIS FOR ti>� THE LOCAL AGENCY IMPLEMENTING ITHE �UNDERGRO�TORAGE TANK REGULATIONS FORM A (6-95) 10 -1 X77 G.i y y T/3�� 66 5/ao%e