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i i <br /> p�4S C <br /> STATE OF CALIFORNIA ...... <br /> Ar <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA .a . or <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> •Cil lfpq N� <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Rr_>rA ���-ai Ck_\�-. Ram �TfaT i®tom a \�1 C <br /> ADDRESSN REST CROSS STREET - PARCEL#(OPTIONAL) <br /> A ` ♦C.C.CA—X Ili'—U %C?\ -®ems.\ <br /> CITY NAME STATE ZIP CODE _ SITE PHONE#WITH AREA CODE <br /> S�C�C-K.i�t� CA �- Z.\!Z:�, 2CA 951 ?_\ <br /> ✓BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'It owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST _ <br /> TYPE OF BUSINESS S;�T 1 GAS STATION Q 2 DISTRIBUTOR a ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS a_ CAI_Cz:k1p0_a5A <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME LAST FIR PHONE#WITH AREA CODE <br /> C Ot 'A F— ft-413--S&ZA <br /> NIGHTS: NAME(LAST,FIRST) ® PHONE#WITH AREA COD.05 E <br /> "�LL NIGHTS: NAME FI���T) , �A,� - PHONE#WITH AREACODE <br /> 111. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> f GGFUJNN{{ e "'�� 1V (/ri�� 115114-Z-3-, <br /> NAME CARE OF ADDRESS INFORMATION <br /> Cl <br /> MAILING OR STREET ADDRESS t/ box to indicate [/]jNDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY N Sic) <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S—\o, <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> EAR <br /> C Cj <br /> MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> E50 x to© QI-CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S411A QA.Moc� Com. R F-S 84a 8500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - ,---� I IqT-5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SI T ) TANK OWNER'S TITLE DATE MONTHMAYNEAR <br /> LOCAL AGENCY USE ONLY R..Aie-, E b ;)--3 1 " t) <br /> COUNTY# JURISDICTION# FACILITY# 3j 11 <br /> LOCATION ODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS F09M 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) 6 %/ <br />