COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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�Ehs CO STATE OF CALIFORNIA OY I.. :! r STATE WATER RESOURCES CONTROL BOARD W dam, v UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT E 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE_ ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Q.UI - -76v all(K- 57-oP M411- /mac . ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL)l6�_ ��0 3o S, o L►✓E A-VE- Morn) 5? r s7 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 5To c(=Tont CA q5z O S 2041- '7+S-6-7 31 ✓BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public age ,complete the following:name of supervisor of division,sedion or office which operates the UST TYPE OF BUSINESS FVI 1 GAS STATION 0 2 DISTRIBUTORQ v1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 2 GSL 6010 SFS gQq 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS � EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE BA KEiZ G/1AD to-(,, -$Son kA"EL'07 Nh I� 5l o-657- -915-0,0 NIGHTS: NAME(LASt.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE �ftKE�2, gQ�-D Si o- - !��2 �p \/6-L-o? VN I KE 570 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION W l L Soxfl-F-P&)J ._-- MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY ! 2 PA LO J41 LL CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE bos /4(-?o 5 (-I I L'I,S C,4 CT4022- III. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION (2.v(K STEP mAct.KAI-7S rN C- MAILING OR STREET ADDRESS y� (^ to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 456'-7 G v L � C n'�J E LS 7 ✓ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 1=2�!•'LOprT I tit 7-1-53 8 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F474- - 1161 T6 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED Q 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION M 7 STATE FUND 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 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.a III. Dd THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT i TANK OWNER'S NA ( RI ED SI ATU E) TANK OWNER'S nTLE Lia DATE MONTHIDAYNEAR MIKE mrA pwr LOCAL AGEN SE ONL T l 7 �) COUNTY# JURISDICTION# FACILITY If ('(00 F;1UP LOCATION C E -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 UNDERGROI TORAGE TANK REGULATIONS FORM A(6-95) _ �'•