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4 1 r <br />ou-°Fs <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 5�r_J NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED. SITE <br />ONE ITEM 1:1 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME, � � <br />� 'r <br />� � NAME OF OPERATOR <br />Gi(OPTIONAL) <br />ADDRESS ,S i <br />AIllfff <br />NEAREST CROSS <br />PARCEL <br />CITY NAME <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />—7 <br />STATE <br />CA <br />ZIP CODE y <br />57 r." ,59 <br />SITE PHONE # WITH AREA CODE <br />9--"s,_/ ✓ Z9 <br />be BOX Q CORPORATION <br />Q INDIVIDUAL CFePARTNERSHIP Q LOCAL -AGENCY [Q COUNTY -AGENCY' Q <br />STATE -AGENCY' Q FEDERAL -AGENCY' <br />TO INDICATE <br />DISTRICTS <br />' d owner of UST is a public agency, complete the blowing: rens of supeNeu of dvWm, section or office which operates the UST <br />TYPE OF BUSINESS a 1 GAS STATION 0 2 D18TRIBUTORRESwl <br />IF INDIAN ERVATION <br /># OF TANKS AT SITE <br />E P. A. 1. D. # (optional) <br />Q 3 FARM <br />Q 4 PROCESSOR <br />5 OTHER <br />OR TRUST LANDS` <br />i <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAY NAME (jAST, FI e,6 2019 <br />9 # WI5�� COO 0 DAYS: NAME (L�4ST, ST) PHONE N WITH AREAPODE . <br />IWAV <br />NIGI j NA ST. FIRST) W 6 /���PHONE AREA CODE NIGHTS` -44AME ) fjT) / PHOfV�EWITH AREA C���i� <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) /)J �1 JY JJ� / G Jt'•� <br />NAME � <br />z <br />/ C <br />&V-? e <br />TANK OWNEA'S TITLE <br />CARE OF ADDRESS INFORMATION <br />✓ boxtoirWiate Q INDIVIDUAL <br />MAILING ORTREET DRESS <br />7 <br />�� <br />�. <br />dra <br />✓ box to Q INDIVIDUAL <br />Q CORPORATION I�ARTNERSHIP <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />—7 <br />CITY NAME Z <br />ZIP CCODE <br />STATE �Q ZIP COgEa i <br />�; <br />PHONE # WITH AREA CODE <br />fit^ Fj/C-' <br />III. TANK OWNER INFORMATION -(MUST BE COMPLETED) <br />NAM NER / -S V/ C/ <br />CARE OF ADDRESS INFORMATION <br />TANK OWNEA'S TITLE <br />MAID O §1EE AD ESS � <br />'� <br />✓ boxtoirWiate Q INDIVIDUAL <br />Q LOCAL AGENCY Q STATE -AGENCY <br />t� 0 <br />Q CORPORATION RSH <br />PARTNEIP <br />Q COUNTY -AGENCY Q REDERAL•AGENCY <br />CITY NAME <br />STATE <br />ZIP CCODE <br />PH2 I21 ✓ ✓ <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ F4747- <br />- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate Q I SELF-INSURED Q 2 GUARANTEE SURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE RIND <br />Q 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND & CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT. MECHANISM Q 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.7 II. Eji:_ III. <br />THIS FORM HAS BEEN COMPLKUN,B-'�ENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TAPOWN�E-R'S N <br />RINTED SIGNATURE) <br />TANK OWNEA'S TITLE <br />OATS MONTHiDAY/Y% P -AR <br />C J <br />)& <br />os .d'Z.it <br />J <br />,/ <br />may/ <br />C/ <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (6.95) <br />J <br />