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• '.UR C <br /> C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD w <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM AA <br /> Ci COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ` . <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACT NAME NAME O OPERATOR <br /> vo . �lB� e411- (_b: <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 135-2,4-0 apcl - 31 Zztl-r <br /> ✓ BOX <br /> TOINDICATE O CORPORATION (�INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR0 gESERVATIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS L�COCJC'Z l to 7,q <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH f REA CODE DAYS- NAME(LAST,FIRST) <br /> CtA KQ J 3ai't — `c�-�� ✓n k 'nGCt- C7 <br /> NIGHTS: OWE AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> clk"r-o v, R0,46v,� 890- -772. -3 3 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECL, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 7E. Q- V L` Sc>O CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S CA 9L(S-8 3 -t o--eq-Z - `a?-5c)o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF QWNERCARE OF ADDRESS INFORMATION <br /> V-0 Y` r'8 G �j <br /> MAILING OR RSEETADD ✓box to indicate INDIVIDUAL <br /> Q LOCAL-AGENCY OSTATE-AGENCY <br /> _ �. hb CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME IS STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ste.- CA ((< 3 15 to 8q-z -- 5�5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - LI 3 i <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> = 5 LETTER OF CREDIT Q 6 EXEMPTION 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 /> F <br /> ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: f�n II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATUR APPLICANTS TITLE DATE MONTWDAYlYEAR <br /> Tb"AS3 /1�4 i - A3 s 7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCAIO�,CODE -OPTIONAL CENSUS�RAC PT/ONAL SUPVIS DISTRICT CODE -OPTIONAL <br /> �_ �,� 3 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS F SITE INFORM N ONLY. <br /> A C G O <br /> FORMA(5-91) FOR0033A-5 <br />