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STATE OF CALIFORNIA �..`";°�"� +� STATE WATER RESOURCES CONTROL BOARD u d®, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3e - COMPLETE THIS FORM FOR EACH FACILITY/SITE 1�' " MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION 7 PERMANENTLY CL ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR i orr. r ,M Messner ADDRESS NEAREST CROSS STREETPARCEL#(OPTIONAL) Co ! D 4I`VIL 6 2 r A r°r Por? Ww CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ^7 o 'vL CA ✓r,20 (o ,zOq q$,2 ' 2 2 ✓BOX �I CORPORATION C-1 INDIVIDUAL PARTNERSHIP ED LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' D FEDERAL-AGENCY- ToINDICATE DISTRICTS -Novmerd UST is a public agency,=plate the InllowNng:1191 nedsupervsoroldivision,s ionorolioswhichapelelesthe UST TYPE OF BUSINESS I'Q'1 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Optional) ��I RESERVATION 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS O N E EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRSIT PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH REA CODE Y-. o berY M sMer 144?1 9'33 )C �r%m Me e N�Avt^50- re NIGHTS: NAME(LAST,FIRST) NIA PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 5 C, OL Lt. I IA Mrr Aa ,.. D eH lis MAILING OR STREET ADORES G�^ }� r 1' ✓ boa W indoale 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY Q 0 ✓O , (' / O Y'r W O?+ ED CORPORATION 0 PARTNERSHIP K COUNTY-AGENCY [:1 FEDERAL-AGENCY CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE 5"ToC- k-rc n 0G 606 �o bQIc{7QO III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MN, Me ne- - / i hT S L 13 Y' L� MAILING OR STREET ADDRESS � ✓ box to ndpl C:3 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY ;z Q (�, Q �/` CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 5- �/o c-47-o vs- CA I9S"2 0 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4 -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Wx to iMicate 1 SELF-INSURED O 2 GUARANTEE X 3 INSURANCE =4 SURETY BOND Q 5 LETTEROFCREDn Q 6 EXEMPTION O 7 STATE FUND D8STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 19 LOCAL GOVT.MECHANISM 1 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.0 11.0 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED& TANK OWNER'S TITLE MONTHYDAYNEAR ii,e t SIGN DATE /-1a-98 LOCAL AGENCY USE L �� COUNTYV JURISDICTION M FACILITY m16-101 -719 b LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL kre I Z3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6.95) � b/, �� ((//�I � OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S ORA TANK REGULATION$,/+