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R 0 • tgOURC(S STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W der a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , o= COMPLETE THIS FORM FOR EACH FACILITY/SITE C�I,IOR N,� MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY.AfMI-D"SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME QU t K 52oP I►�4/Nt r. E7 12 I NAME OF OPERATOR Q U l!�._ ADDRESSI 1 � P WeS7 I� 0(5E 5-r NEARS )ACROSS STREET 1 PARi :1TON+I D CITY NAME STATE ZIP C ODE SITE PHONE # WITH AREA CODE 14pov76-cA Ca 533 Zo9 239 X95 -j!- ✓ BOX CORPORATION INDIVIDUAL = PARTNERSHIP Q LOCAL -AGENCY COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS ' ff owner of UST is a public aprxy, complete the following name of supervisor of division, section or office which operates the UST TYPE OF BUSINESS �1 GAS STATION Q 2 DISTRIBUTORRESERVATION ' IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS I 3 CAL GDO 045- Qza EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) tAKFIR— 5P -4D PHONE # WITH AREA CODE 5710 65a- 85-0-o DAYS: NAME (LAST, FIRST) K UEZo M.l IcE PHONE # WITH AREA CODE Sro (05--2' —8S-2) NIGHTS: NAME (LAST, FIRST) BA-I� pkAD HONE#WITH AREA CODE S"►9 4`x'8 - I �+2- NIGHTS: NAME (LAST, FI ST) Ezo JMIlr& P ONE # WITH AREA CODE sco -- 0'T3 II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAMES CARE OF ADDRESS INFORMATION t ' rV ,� wI &fb-P_ 7G e i�/✓�%� �I� I Zt� MAILING OR STREET ADDRESS MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY C' IQ � �rL` (� Q CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME SAS 7o SE STATE CA -17S-1-32— ZIP CODE PHONE #WITH AREA CODE S -- 2-S-8-1-3 2 - Ill. Ill. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER a U l V S Za P MA2-t=&7S It"-- CARE OF ADDRESS INFORMATION All k6 �- - VEZo DATE MONTHIDAYNEAR `-} MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL -AGENCY O STATE -AGENCY P. D , B Zia -CORPORATION PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE E # WITH AREA CODE �rfrlzo /"li 09T 1453 63-9- ss -era IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ F4]4-] -1011 g -- 6I V. PETROLEUM UST FINANCIAL RESPONSIBILI - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED = 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND O 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT = 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. ❑ 11- 1:1 III. THIS FORM HAS BEENjCVMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME( INTEDF '1vrU__ TANK OWNER'S TITLE DATE MONTHIDAYNEAR `-} MIK£ ✓, ASK- pLAY-T. /hN&/L . 1 C9 0e. -r- LOCAL AGENC1X11,SF�dNLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT ST (1) OR MORE PERMIT APPLICATION - FORM B, UNLEJ&IS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (6-95) OWNER MUST FILE THIS FORrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRIW STORAGE TANK REGULATIONS