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ounces STATE OF CALIFORNIA 7 STATE WATER RESOURCES CONTROL BOARD W , a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE XZ 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) !25 #- Z p -- `l 91 DBA OR FACILITY NAME NAME OF OPERATOR r �M GIS �`o✓\S �..rG. ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE o,.v` c o•- CA OZS-, 017 ✓ BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' TO INDICATE X DISTRICTS 8 owner of UST is a public agency,complete the following name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RE*1 IF INDIAN 1 SERVATION #OF TANKS AT SITE E.P.A. 1.D.#(optional) 0 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If �w r .v (-000- 423-d /I Ck� -'90 i taii4�0 2- -45"f NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 611k-e v v-o v-k-N -ter / d0 -L ,I -O d Z II. PROPERTY OWNER INF RMATIO -(MUST BE COMPLETED) NAME II (� CARE OF ADDRESS INFORMATION . G YV.-VF— MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY P.O. 13o-?4_ 6 00 4 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY N Mww elA �U L^_ STCA E ZIP CODE �� PINE#NTH 1002- III.STANK OWNER INFORMATION-(MUST BE COMPLETED) (/ 0 4IL NAME OF OWNER CARE OF ADDRESS INFOR TTIION ` e—5 k— wm MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY U- (� f✓ [ CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE21P CODE PH NE#W AREA CODE i!�4 j q-5_0 3 941_2 041-15 Z IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ -4 - 3 �j V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 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. / THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT SAME(P NTED SIGNATURE ANK OWNER'S TITLE DATE NTHiD /YEAR A_5 y 4- LAE24 LOCAL AGENCY USE ONLIYrl COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FORIW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRSTORAGE TANK REGULATIONS