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a°U"°�s <br /> STATE OF CALIFORNIA Ae cO� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT /6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM D 2 INTERIM PERMIT Q ' 6 4 AMENDED PERMIT I TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> QVw- sToP 1(. GWIK 5'u,10 MAOP_c-_P S /NC <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 10 S. OL-1 VE 14V6 M-Ar)/J 57 15'7 --2—Gt-ZZ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> SToC KTo1.1 CA 95-2-05- 2txfi-948 - 67 31 <br /> ✓ BOX CORPORATION (] INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY E::]COUNTY-AGENCY' (]STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'II owner of UST is a public age ,complete the following:mama of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORQ v1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION OT.� sqj <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS Z CAL, 000 v"1 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 13AKE2 , BRAD SIo-65']- Soo kfi2VELur Mi Ke 51DI 657-5500 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SIO -448 - 1-1'7 2 KA42V e L a7 M I Ice S710 44E)-09 34 <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> wlLt iAm Sc,KPr2FEN <br /> MAILING OR STREET ADDRESS 1 , ✓ box to indicate 0 INDIVIDUAL O L CAL-AGENCY E::]STATE-AGENCY <br /> -2, ;7 L Pq L.1D Li'I LLS (7Q F7 CORPORATION F7 PARTNERSHIP F-1 CO NTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> L.C>S AL7o5 I's IDS <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> (3,01K SToP MA&VI S WC . <br /> MAILING OR STREET ADDRESS <br /> .� ✓ x to indicate (] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 9 S(o'1 '& (,C'��fa 67 C CORPORATION (] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> kr-r�a� G4 a(9-S 8 510-X57-6500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -1 c I 101 1 �_ 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION En 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 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: I. II. 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 <br /> (PRIN IGNZT1I TANK OWNER'S TITLE ATE MONTHIDAYNEAR <br /> M I _i✓ <br /> A"144 Wr M �►G 28 �5dL '�g <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO9TORAGE TANK REGULATIONS <br />