COMPLIANCE INFO_1985-1999 - Laserfiche WebLink

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r�f,OV aC!9 STATE OF CALIFORNIA Ar STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE • ��t.aaw`� MARK ONLY f7 1 NEW PERMIT F—] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO ONE ITEM [:] 2 INTERIM PERMIT O 4 AMENDED PERMIT ,P�Q6 TEMPORARY SITE CLOSURE 101 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME Z* NAME OF OPERATOR QV i K S`CoP r4,0c2k-eT 12-5 Quo< SZoP l'vl L1L-ET5 /I�C� ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAL) 158 01 ll�f}�/J IZ 1 Pohl V-6 JAG6L ZoitlE 11ofrD 7,Sq- Oqo -ZI CITY NAME STATE ZIP CODE 9TE PHONE#WITH AREA CODE 6Z1 Pont Ca 6-3 6 6, Z01' S-7-T— Z6 l ✓BOXCORPORATION (] INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' (] STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If 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 Q 2 DISTRIBUTOR a ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION GAL D 00 QQ S �f 2 3 0 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST(ANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE P(Ct B �Io �s� - �� Flo � 5_/0Szy'C> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE kms-1 64.0-0 s r o 4 416 , 1-4--Z IM I 4/_F 5,CO 440 —oq 3 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION WI(,(,I AM 5G Pl MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY Yf UL5 =CORPORATION =PARTNERSHIP (] COUNTY-AGENCY DFEDERAL-AGENCY CITY NAME STATE ZIP CODEPONE# ITH AREA CODE LOS Pr�-TOS GR" q46 ZZ ,'1,5 82-1' 6r 108 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION au 1 K S7p'v fv-KC-7S I nl G Wl j K-E rjk2VEL6)7 MAILING OR STREET ADDRESS ✓ boxio indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY D eCS +5' P�g CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE 1,PHONEWITH AREA CODE rg�WT I 44tcl t53 1510 6 _ 656-n IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- -101110 1� 3 V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE M 3 1NSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND 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.= it.[::] III. THIS FORM HAS BEEN COMP ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED SIGN TU ) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR Nb I KE L6 IM2-Cij. De'T In il/G2. to � ` LOCAL AGENCY USE COUNTY# JURISDICTION# FACILITY# / m17,1 31 I Ir (4�y LOCATION CODE -OPTIONAL CENSUS TRAC # -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 5 C;> f f 13 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)