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esou�ces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A A _ COMPLETE THIS FORM FOR EACH FACILITY/SITE •C�l.iOn M.r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [: ] CHANGE OF INFORMATION ❑ 7 PERMANENTLY E TE V ONE ITEM ❑ 2 INTERIM PERMIT E::] 4 AMENDED PERMIT TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) G2VIK--S7oP X29- �) DBA OR FACILITY NAME NAME OF OPERATOR II l I3I &UI IC SToP $r2 aUIK 5T.OP �►'jA2l ?S ING. ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 5o S 1\)o�_7K M.4,14 Sz�� A U,4M FIC) ZI':- - 26 0 --2-) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ca g533(a � - 8z3 --�6 29 ✓BOX 2fCORPORATION E::] INDIVIDUAL [::] PARTNERSHIP (]LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS ff owner of UST is a public age ,complete the follow ng:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR 0 RESwl ERVATION INDIAN #OFTANKS AT SITE E.P.A. I.D.#(optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS J GAC. 00001-T11,?Z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 13�►K B ZAP S�a� (05� -8S� Kpoe..v6LO wl!1cE 5f0 (oS? -435 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ►� pJ f2,4o 15,0) 10 44t - 1-1-12 k-- , VEt 6T M I kt Sl 1 440 -09 3 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION C �Vmc y�M�►s�tlt� MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL i7 LOCAL-AGENCY STATE-AGENCY 344r6 GAN y o j G 9_L:EIL 02-I✓L, =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 5"j Jo565:' cR q S1,3 z 4o8--2-Ss-4 3-+2 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION aV lK 5TsP MALLS MAILING OR STREET ADDRESS c �.✓,(Jwx to indicate INDIVIDUAL (� LOCAL-AGENCY STATE-AGENCY C 90�e� .� 4S(�7 ANTE PK{SE J�, �CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE �4GKotrr CA_ x'4538 510-65-9- 85&0 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- -�> I 18 1�(P 3 V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE 9F, INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION 717 STATE FUND 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 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.d THIS FORM HAS BEEN?6M LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRI ED& GNA R TANK OWNER'S TITLEDATE MONTH/DAYNEAR m I K-6 te-F ARM. P"r /UA4�9,- A*CZb,,d .4 LOCAL AGENCY US LY COUNTY# JURISDICTION# FACILITY It J LOCATION CODE -OPTIONAL 7� CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL O_6H THIS FORM MUST BE ACCOMPANIED BY AT ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRgTORAGE TANK REGULATIONS f 11 FORMA(6-95) '5 5