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`4Oumc♦:s �7 STATE OF CALIFORNIA 7 STATE WATER RESOURCES CONTROL BOARD s UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A A$ COMPLETE THIS FORM FOR EACH FACILITY/SITE au 11 MARK ONLY 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Quw- STof "Uo aut`K s- otP mAr2+rcFr4 /tic , ADDRESS /0 3a 5, ©f l VE 4``e NEARESTMAIN A/ SSS STREET PAST IR (OPTIONAL— i CITY NAME STo To AJ i• Y STATE 1 J,/ZIP CODE- SIITEsPHONE#WITH AREA CODE CA CT520S Z.Oq_ q48- (731 ✓BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP a LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION ❑ 2 DISTRIBUTOR 0 IFINDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 4 L Q 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS " 000 C45 iaTj EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRS04 T, PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE SAKI 1 AAC) $/a-657'8500 K40-vad-r, %�Kf 65-7- ?5-bo NIG NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE /Z. $Q�Q 51 C>— ¢+e- 1.71Z FkVE�OT I!Ktr $i o - 4¢p -- 6q 7,,,s-ef- II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION W1(C 1AM sc)N IZFG: J MAILING OR STREET ADDRESS n ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY &-7 9 Z PALO MILLS Dk CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP C I G.L PF(O_NE#WITH q F ;Ir Ds �,.�%S' /a CTo S }rl'I t 1.5 . , i�►i S 9 TR f III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCARE OF ADDRESS INFORMATION Qvtk SToP mctwe+ 7.5, 1NC MAILING OR STREET ADDRESS ✓ x to indicate Q INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY TS("-7 er4 f -e K CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAM5. n Mp STATE ZIP CODE PHONE#WITH AREA CODE ,�-�' r `�753 8 Sic>- 165,7-85"00 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- - C 1 ' V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box 10 indicate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND 17-15 LETTER OF CREDIT 0 6 EXEMPTION 7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 OTHER 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 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S IN E(PRI ED j SI ATU E) TANK OWNER'S TITLE h�MC`Fflr/ DATE MONTHIDAYNEAR MIV-C { Cir pert'��/ LOCAL AGENCY USE ONL 1) 3 `7 COUNTY# JURISDICTION# FACILITY# LOCATION E OPTIONAL CENSUS,T ;# -C�7PT10 AL SUPVISO�I®ICj CO OPTIONAL THIS FORM MUST BE ACCOMPANIED B�Y,,II�yAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROSTORAGE TANK REGULATIONS 6 -J'- ' 7 �