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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD Y� , f UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM E] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILIr{NAM NAME OF OPERATOR { IY1x`I� �.-tdYM �YN4�CIti l�cl�apit �• f�crlr�- VCCvlo 13ass0 1 _ ADDRESSI NEAREST CROSS STREET PARCEL N(OPTIONAL) y +Of sovlk LIkIc.>,�N s�. c�lt�vcl7 s+. CITY N{{��ME STATE ZIP CODE SITE PHONE#WITH AREA CODE Si'o4tvV -5I97- J BOX E6 CORPORATION Q INDIVIDUAL [] PARTNEASHEP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' © FEDERAL-AGENCY' TO INDICATE DISTRICTS I owner of UST is a public agency,complete Vie following:name of supervisor of division,section or office which operates the UST [TYOF BUSINESS a I GAS STATION IJ 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.N(optional)RE SFRIATION optional)RESERVATION Q 3 FARM Q 4 PROCESSOR lz� S OTHER OR TRUST LANDS j EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 'b"(SSo VCCvIi,? Zo9- tkaLo 11 ?- NIGHTS: NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE BCIS S49 Jc�cvrPi 2-o1 -4(ato- 5112 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION F�evII7 Sasso I t•"' MAILING OR STREET ADDRESS ✓/hoz to 7ndraIe Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY I I L�S W. C k IV, GI- W a1 L COAPORATION Q PARTNERSHIP Q COUNTY-AGENCY © FEDERAL-AGENCY 1 CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE , s}oc� -off G 9520 to zoq - 4caLe-619 Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION K_�VI VI �i 5S t7 I MAILING OR STREET ADDRESS L ✓ r to indicate Q rNOIVICUAL Q LOCAL-AGENCY Q STATE-AGENCY c k etY" C Y W vi CZORPORATIDN Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL•AGENCY CITY NA E I STATE ZIP CODE 7PHONE#WITH AREA CODE Si o��tos7 C� 15-2- 2. o -4 toly IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. I TY(TK) HQ M44- - I V. PETROLEU UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Dox Eo indicate iSELF-INSURED IQ 2 GUARANTEE © 3 INSURANCE Q 4 SUPETY BOND Q 5 LETTER OF CREDIT [� 6 EXEMPTION [Q 7 STATE FUND © S STATE FUND d CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND S CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT,MECHANISM Q 49 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: I.D II,[�j III.a THIS FORM HAS DEEN COMPLETED UNDER PENALTY QF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE ANO CORRECT' f TANK OWNER'S NAME(PRINTED&SIGNA £) TANK OWNER'S TITLE DATE MONTHfDAYIYEAR kGvI� SS 0 . Dln/h�V j '7 �f LOCAL AGENCY USE ONLY i COUNTY it JURISDICTION# FACILITY N ETI LOCATION CODE •OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 13,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) J