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STATE OF CALIFORNIA ',e c STATE WATER RESOURCES CONTROL BOARD ' d� ; UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e - , i� . COMPLETE THIS FORM FOR EACH FACILITYISITE MATION Q. ADDRESS - (MUST I3E UUMFLE I IZU) I. t-AUILI I vol I r INFOR ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ITE MARK ONLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ADDRESS Zy'va cv • Gam MATION Q. ADDRESS - (MUST I3E UUMFLE I IZU) I. t-AUILI I vol I r INFOR /•� /� p n DBA OR FACILITY NAME NAME OF OPERATOR JURISDICTION # FACILITY # 2 � � -- • NEAREST CROSS STREET PARCEL # (OPTIONAL) ADDRESS Zy'va cv • Gam MAILING OR STREET ADDRESS V O CORPORATION O PARTNERSHIP STATE ZIP CODE SITE PH E # WITH AREA CODE CITY NAME CA 17 Z% 9 33-4i&' ZIP P, 4 \TN� F -AF 2— 2 61BOX Q CORPORATION INDMOUAL O PARTNERSHIP 0 LOCAL -AGENCY 0 COUNTY -AGENCY' IF] STATE -AGENCY' a FEDERAL -AG CY' TO INDICATE DISTRICTS ' the 10110wing name d supervisor d dNLsion, section MCNke which operates the UST d ovmerd UST H a pubbe agency. =plate # OF TANKS AT BITE E. P. A. I. D. # (apliDnal) ❑ TYPE OF BUSINESS ❑ 1 GAS STATION E::]2 DISTRIBUTOR RESERVATION Q 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST IANOS EMERGENCY CONTACT PERSON (PRIMARY) tmenvoY�r wts u.sa'-- -r---- DAYS: NAME (LAST, FIRS PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE #WITH AREA CODE a t� ?4L� (Zvsl) 3�3 - T,? �NIGHTS: NAME (LAST, FIRST) PH NE # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) PHONE #WITH AREA CODE �- uz s? ..r.,nT nluueo IA¢nOSAATInM -IMI IST RF COMPLETEL)I NAME /•� /� p n CARE OF ADDRESS INFORMATION COUNTY # JURISDICTION # FACILITY # 2 � � -- • �6/��s ✓ boeto rduee = INDIVIDUAL LOCAL -AGENCY O STATE AGENCY MAILING OR STREET ADDRESS V O CORPORATION O PARTNERSHIP O COUNTY -AGENCY O FEDERAL -AGENCY CITY NAME LOCATION CODE -OPTIONAL STATE •s ZIP P, 4 \TN� F -AF 2— 2 III. TANK OWNER INFORMATION - (MUST BE CUMNLE I EU) NAME OF OWNER �y CARE OF ADDRESS INFORMATION MAIL�LNG OR STREET ADDRESS ^ ✓ Ooeto ndkate � INDIVIDUAL LOCAL -AGENCY I� STATE -AGENCY '/�; G" �"' (� CORPORATION PARTNERSHIP OCOUNTY-AGENCY QFEDERAL-AGENCY STATE ZIP CODE PHONE # WITH AREA CODE CITY NAM oL.�vy IV. BOARD OF EQUALIZATION UST STORAGE FEE AUGUUN I Numoen •Lau le I DI Jcc DuuD n R��rn TY (TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED 1 SELF-INSURED O 2 GUARANTEE l� 3 INSURANCE = a SURETY BOND Q 5 LETTER OF CREDIT = S EXEMPTION = 7 STATE FUND ✓ Galt to irdicale O 9 STATE RIND 6 CHIEF FINANCIAL OFFICER LETTER = 9 STATE RIND B CERTIFICATE OF DEPOSIT = 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. ❑ II. III TNLc FnRM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED B SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR naD v Tutc Cr Dsa All Dc Arrnuomirn RV AT I FAST NLOR MORE: PERMiTAPPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY OWNER MUST FILE THIS FOR vH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO0STORAGE TANK REGULATIONS FORMA (6-95) COUNTY # JURISDICTION # FACILITY # 2 � � -- • �6/��s m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL' OR DISTRICT CODE - OPTIONAL Tutc Cr Dsa All Dc Arrnuomirn RV AT I FAST NLOR MORE: PERMiTAPPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY OWNER MUST FILE THIS FOR vH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO0STORAGE TANK REGULATIONS FORMA (6-95)