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I <br />• <br />LJ <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />PtgO'unClS C <br />wP o <br />0 <br />3 0 <br />W MO <br />o <br />MARK ONLY 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MLI5T BE (;UMPLETEU) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />c 'aM, <br />Apa444 <br />ADORES <br />�Q <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />.ow_ ,�/IL F- <br />r1 <br />�__5 <br />5 cQdvAg�90 <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />PSCL &IV <br />CA <br />? 0 <br />Za � -- <br />✓ BOX Q CORPORATION (INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL -AGENCY' <br />TO INDICATE DISTRICTS <br />' 9 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 1 GAS STATION a 2 DISTRIBUTOR <br /># OF TANKS AT SITE <br />E.P.A. I. D. # (optional) <br />RESEIRFINDIAN VATION <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAY & NAME (LAST, FIRST) P#�WIITH AREA CODE <br />� <br />Ll ail <br />/HONE <br />.26 SST A?_ <br />NIGHTS: NAME (LAST, FIRST) PH NE # WITH AREA CODE <br />NIG S::NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />kAdjV_,0 R91211&4 <br />/" S ,-. <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />� <br />GL/.S <br />MING OR TREET <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />�__5 <br />5 cQdvAg�90 <br />0 CORPORATION PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />La" <br />STATE <br />ZIP CODE <br />CITY NAME <br />PHONE # WITH AREA CODE <br />_1d . <br />t <br />ZIP ODE <br />0.,5 <br />PHONE It WITH AREA CODE <br />�3 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />Ng Of OWNERS <br />i Amo <br />CARE OF ADDRESS INFORMATION <br />MING OR TREET <br />ADDRESS <br />✓ box to indicate 0 INDIVIDUAL <br />0 LOCAL -AGENCY <br />STATE -AGENCY <br />CORPORATION � PARTNERSHIP <br />= COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP ODE <br />PHONE It WITH AREA CODE <br />4/.51 <br />6nC J �/] <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) # 4 4- - C) <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHODS) USED <br />I ✓ 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 <br />8 STATE RIND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. MECHANISM = 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. ❑ II. 0 III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # 7/o <br />F-1-1 FFTI a11 H 1g, <br />LOCATION CODE -OPTIONAL CENSUS TRACT # ;OPTIOO AL SUPVISOR - DISTRICT CODE - OPTIONAL 02 <br />THIS FORM MI IST RF ACCOMPANIFn RY AT I FAST (11 OR M_dR_ F PERMIT APPLICATION - FORM R. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROTORAGE TANK REGULATIONS <br />FORMA (6.95) <br />0 G 7 <br />(a -4-10P <br />