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• • xaow�i STATE OF CALIFORNIA s �� STATE WATER RESOURCES CONTROL BOARD u dam, e e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <n _ , o COMPLETE THIS FORM FOR EACH FACILITYISITE :tl MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION CB 7 PERMANENTLY CLOSED.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 NAMEOFOPERATOR s,vc,+-To,✓ TEQN/N 4L 57Vx._70/v 7-641_1,1A1,44_ ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) N 51-144 1 R_OfID �yJEiNIJ�t/9' CITY NAMEy / ST CA ZIPf,OODEE 1 02ITE PHONE#WITH AREA CODE 646-7001 ✓ Box IWCORPORATION 0 INDIVIDUAL Q PARTNERSHIP ❑I-MALAGENCY O COUNTY-AGENCY' O STATSAGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS X ovmerof UST is a pubGcagenry,coMlete the lolbwng name ol superviscrol divBion,section wdlice which operates the UST TYPE OF BUSINESS ❑ T GAS STATION Q 2 DISTRIBUTOR ❑ ✓IF INDIAN 1#OFTANKS AT SITE E.P.A. I.D.#(apticnaq RESERVATION ) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRSn PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ] c4Rn/ y, 249 7kxw/ NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �r�l✓Eiv 11E41_11v 62vtvo)9,fz–S/f6 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION TrJN TES//n/�L E/15TECAJ � IL MAILING OR STREET ADDRESSI� ✓ box loiMCale INDIVIDUAL ❑ LOCAL-AGENCY 0 STATE AGENCY Np STN, L(�F n�✓/4 Q CORPORATION O PARTNERSHIP ] COUNTY-AGENCY O FEDERAL-AGENCY CITYNAME STATE ZIP CODE HONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS 7 ✓ boxbodcah, Q 04DIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 1330 NO,a.T/4 BK UCORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 570' Tor/ G'`1 W3e,5 a9�5/66-7uo/ IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 pZ y V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED h ✓box 10 ir4cate 1:3 1 SELF-INSURED 1::] 2 GUARANTEE E:)3 INSURANCE E3 4 SURETYBOND O 5 LETTEROFCREDIr ED 6 EXEMPTION L-1 7 STATEFUND 08STATE FANO&CHIEF FINANCIAL OFFICER LETTER 09STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O WOTHER 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 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED&SOMA ) TANK OWNERS TITLE DATE MONTHIDAYIYEAR N� LOCA AGENCY UStONLY V C157— COUNTY# JURISDICTION# FACILITY# F-17 LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO#TORAGE TANK REGULATIONS FORMA(6-95)