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STAT R RESOURCES CONTROL BOARDE OF CALIFORNIA STATE WATE`s "'�►� ee�o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s .- COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I_ FACILITY/SITE INFORMATION & ADDRESS -(MUST BE COMPLETED) S S AW ','Po — 1-7 6 DBA OR FACILITY NAME NAME OF OPERATOR - �� OrS ifk4eV•� �-dM PHONE M WITH AREA CODE o Z -6 ADDRESS /� NEAREST CROSS STREET PARCEL I (OPTIONAL) `�d ..> �� �Y-O 1 - ov--231-062 CITY NAME C�� STATE CA ZIP CODE 3 -15- 3 I/ SITE PHONE WITH AREA CODE 20� oZr5-, 013 ✓ BOX CORPORATION Q INDIVIDUAL O PARTNERSHIP (] LOCAL -AGENCY F-1 COUNTY -AGENCY' CD STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS • N owner of UST Is a public agency, complete the lo5owirg: roams of supervisor of division, sedan or office which operates the UST TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR INDIAN M OF TANKS AT SITE E. P. A. 1. D. M (optional) Q 3 FARM ® 4 PROCESSOR r 1 5 OTHER RESEIF RVATION OR TRUST LANDS I FMFRt;FNCY CnNTACT PERSON (PRIMARYI EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRSTL Inw r - v\ PHONE M WITH AREA CODE ate " y4- l —000 — +23 -d // DAYS: N ME (LAST, FIRST) �✓I U�Yl,or.>»l PHONE M WITH AREA CODE o Z -6 NIGHTS: NAME (LAST, FIRST) PHONE M WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE M WITH AREA CODE �Y-O 1 - ov--231-062 ZIP CODE I -�d0-Zvi-OdZ PH NEM W AREA CODE �sr 11. PROPERTY OWNER INFdRMATION - (MUST BE COMPLETED) -1-1 NAM C% CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFOR T�M �G MAILING OR STREET ADDRESS ✓ box to Indicate ED INONIWAL F__1 LOCAL -AGENCY STATE -AGENCY ?-0. 19:rCORPORATION Q PARTNERSHIP O COUNTY -AGENCY (] FEDERAL -AGENCY CITY N M�..v ^ tl STC A ZIP CODE I P , N W TH 04 -z --?6)02_ 4 ODE -? 6)o III TANK OWNFR INFnAMAT1nN - (MUST BE COMPLETED) NAME OF OWNER+ CARE OF ADDRESS INFOR T�M �G MAILING OR STREET ADDRESS Gox 0 ✓ box to h"G Q INDIVIDUAL [CORPORATION Il PARTNERSHIP O LOCAL -AGENCY D STATE -AGENCY Q COUNTY -AGENCY FEDERAL -AGENCY CITY NAME e> -v— STATE C 4 ZIP CODE 5-0, PH NEM W AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4- - L( 1 31?] ,711111 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to krd'aate1 SELF-INSURED E3 2 GUARANTEE (::] 3 INSURANCE E3 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION ED 7 STATE FUND I 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND a CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM I3 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. ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ H. ❑ Ill. I�( I / THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT Yt�� FANIE9NN4ER&NAME (PX31NTED SIGNATURE ANK OWNER'S TITLE DATE NTHID /YEAR LOCAL AGENCY USE ON COUNTY If r JURISDICTION p FACILITY M LOCATION CODE -OPTIONAL CENSUS TRACT M - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY OWNER MUST FILE THIS F1 FORM A (6-95) (1) OR MORE PERMIT APPLICATION • FORM B, UN THIS IS A CHANGE OF SITE INFORMATION ONLY. THE LOCAL AGENCY IMPLEMENTING THE UNDERGIMID STORAGE TANK REGULATIONS