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0 <br /> eso�nces <br /> STATE OF CALIFORNIA A�. . <br /> STATE WATER RESOURCES CONTROL BOARD V dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> _ , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE1 .- <br /> °• ,.a ,. <br /> MARK ONLY � NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED. ITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ( 6 j <br /> DBA OR FACILITY NAME NAME OF OPERATOR /ID <br /> 6?U1tc 5ToP MAR-K&[' fZ1 QUIK- S-roio MA-Q-tG67�5WC, <br /> ADDRESS 110110 I,,F`T �QUISc `T NEAREST 1 CROSS T�. PARCEL�II(OP f`Lc) ­1-3 <br /> CITY NAME W J ` J STATEVN ZIP CODE SITE PHONE#WITH AREA CODE <br /> � �t<Gl4 CA Cr 533 Zog-23 q - Zg 577 <br /> ✓BOX CORPORATION Q INDIVIDUAL Q PARTNERSHIP iQ LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> ff 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 g�1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> QESERVATION — <br /> Q Q OR TRUST LANDS 2_ C"t X 00 0�5 �Za <br /> 3 FARM 4 PROCESSOR 5 OTHER <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> �3►4K�2 gR�+D Sia &5-7 -063-CD KAkVELo ►^�I r-65)o X57 _05-M <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ONE If WITH AREA CODE <br /> BA K AD 51�� 4-4a Z K4k\/EL2T W►( KC- S'i 440 -0q 34- <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e ►VoWc PIMA 5 K(Tt* <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL IQ LOCAL-AGENCY <br /> pp������ I/ QSTATE-AGENCY <br /> Gf��l---tF► [Ai V6 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEHONE# ITH AREA CODE <br /> 5AAJ J05 E G� � 513 2 4-08 ZSS-+37 2- <br /> 111. <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �1 K STC)p ►►')A211 _T5 l N r <br /> MAILING OR STREET ADDRESS ✓ boxto indicate Q INDIVIDUAL IQ LOCAL-AGENCY Q STATE-AGENCY <br /> FD 'BC) 5--�T'✓�Le�^ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE JPHONE J WITH AREA CODE <br /> Re mooT C_^ '14-5-5-7 [,5/o) --85-6zo <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - O 8 7 6 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION O 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM Q 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: 1. 11.0 Ill. <br /> THIS FORM HAS BEEN CO ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRIN D SI AT RE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> 1�1(K L rqA2erf OPT MA�a{s� la-- 1 -�R <br /> LOCALAGEN <br /> COUNTY# JURISDICTION# FACILITY# 8 <br /> m Z3bI � � 3 30 37q8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,UNLES A CHANGE OF SITE INFORMATION ONLY. <br /> ( OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR ORAGE TANK GU TIONS f��� <br /> FORMA 6-95) <br /> G % IR b zoc �/0l <br />