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e,6 „n f STATE OF CALIFORNIA `O. STATE WATER RESOURCES CONTROL BOARD sa UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W�� a i; e Y/ �i -4•an ' COMPLETE THIS FORM FOR EACH FA YISITE MARK ONLY F7 I NEW PERMIT 17 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION En-7 PERMANENTLYUOS60'SI EE, ONE REM l77 2 INTERIM PERMIT [::j 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE S� I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBP OR FACILITY NAME Joe CQ&4ey-aNAME OF OPERATOR d e_ C er e ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) 4 N S+ to 0. a 6 CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE S+OoK+ A) , CA BOX TO INDICATE Q CORPORATION [R-NDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY DISTRICTS TYPE OF BUSINESS C�—L GAS STATION O 2 DISTRIBUTOR R,/ IF INDIAN NDIIA #OF TANNy SITE E.P.A. I.D.a(tptima) ESERCI 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING ORSTREET ADDRESS ✓ but WKM Q INDIVIDUAL Q LOCAL Q STATE-AGENCY Z-3a .3 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE a WITH AREA CODE 5 toc + 9SdOS 20- 3- /63 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SO e Ca G MAILING OR STREET ADDRESS ✓ incwtdtiie Q INDIVIDUAL Q LOCAL-AGENCY Q STATEAGENCY 2 3 0 3 e . a T94 de Q CORPORATION Q PARTNERSHIP Q COUNrY-AGENCY Q FEDERALAGENCv CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE S1Ockf #NJ o o -y ' l63 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ Om blNeaY Q 1 SELF-INSURED Q 2 GUARANTEE 0 1 INSURANCE Q A SURETY BOND =5 IETTEROFCREDR Q B EXEMPTION Q N OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O 11. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY XNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY IT JURISDICTION# FACILITY# C14 q-If K51 FTT-1 j0jC9j,:RjSj6j ( 173 LOCATION CODE -OP T9 ICENSUS TRACT -OPTIONAL SUPVISOR-DLSTRICTCOOE -OPTIONAL Z-Z_ — — Z 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(5-91) ROR0_=A;5_