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'punct, P�' •-..ii Cp STATE OF CALIFORNIA .P a STATE WATER RESOURCES CONTROL BOARD W dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , COMPLETE THIS FORM FOR EACH FACILITY/SITE to • C�LIipR H.r MARK ONLY F] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F75 CHANGE OF INFORMATION ❑ 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 R FACILITY NA NA0 � ME F OP RATOR Tri g 0 ADDRESSNEAREST^ A Gwf vtL-aY kD�td C�roOS�EETLaYj� PARCEL#(OPTIONAL) CITY//_NAME K STATE ZIP CODES E PHO E#WITH AREA CODE CA S_4 e) 367- 79S' ✓BOX CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS 'If owner of UST is a public age ,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.#(optional) RESERVATION ^1 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS ..7 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#S�TH AREA CODE DAYS:PAME(LAST,FIRS HON #WITH AREA CODE M)son G Ceryl -1795' He-Inze e (Zc _17#/4 NIGHTS: NAME(LAST,FIRST) PHO E#WITH AREA CODE NIGHTS: NAME(LAST,FI PHONE WITH AREA CODE '' 2©9 4V414�3 A(7_1 r7 Ze 41e. 209 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARWFADDREV INFORMATIO h n s 4 rl knox MAILING OR STREET ADDRESS I ,l ✓ box to indicate INDIVIDUAL ' LOCAL-AGENCY Q STATE-AGENCY &'33—E. ✓ Get d 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY,NAM i STAX. ,� ZIP CQD � FjO F 5t0 AREA 7CODE 5 IIIl/ TANK OWNER INFORMATION- MUST BE COMPLETED), Jyl i (/ J C/ ,/1 NAME OF OWNER BO ► A E QF ADDRESS INFORMATION 15. crar" MAILING OR STREET ADDRESS ✓ indicateQ INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY (42& Q r� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME � STATEZIP CQDE ' ^ � P O�^W TH AREA CODE T'fZ IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916) 9)322-9`6699 if questions ariisse`.+9 9,7/jffJ TY(TK) HQ F474--l-16:31-71 6-91411 V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE EV31NSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND (�8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 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.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT (_—I TAN WNER'S NAME(PRINTED&$�OIATU TANK OWNER'S TITLE DATE MONT fDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 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 JTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIVORAGE TANK REGULATIONS FORMA(6-95)