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T. . <br /> 171" <br /> f � e <br /> STATE OF CALIFORNIA �! a, <br /> STATE WATER RESOURCES CONTROL BOARD mom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILI Y/SnE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. "--t <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS.(MUST BE,COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> e - Qv IV-_ stop <br /> A2zW a-j �R�..,t�c,alJrr�-'�• "�EW ^ST_ 0 ST-_ I+I -SS STREET PARCEL#( x'2.14- -- Z�3 <br /> CITY NAME STATE Z' ' s #WAREA <br /> CCA f!n ,Os —10-- <br /> BOX 112 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOOAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> •8 owner of UST Is a pubk agency, late the fo6cwng:named ppor4or of division,wit or oNEe which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ ?,00TRIBUTOR ❑ ✓IF INDIANVATION #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> Q 3 FARM ❑ 4 1�AGCESSOR ❑ 5 OTHER OR TRUST LANDS 2. <br /> EMERGENCY <br /> ^CONTACT PERS6 (PRIMARY) c <br /> EEM_ERGrENCYCONTACT PERSON (SECONDARY) <br /> SECONDARY)-opTtional <br /> E FIRST) 15WPHONE <br /> DAYS: NAME(LAST,FIRST) <br /> !NE# IH AR =C <br /> DE <br /> � � W <br /> "V%;; r(( kk,J� !5 <br /> NS: AT,FtR PHONE It AREA CODE NIGHTS jE LA RSONE#WITH AREA CODE <br /> kG . © <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME, 1 /'y"�Q�� C E OF ADDRESS INFORMATION <br /> Z)k <br /> OtIA <br /> G OR STaEET ADDRESS INDIVIDUAL LOCAL-AGENCY 0'STATE-AGENCY <br /> f <br /> Mr. , (p CORPORATION ED PARTNERSHIP COUNTY-AGENCY (]FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH EA CODE <br /> t t- v'1 .�r�e I N So n.l (c► 12,b�b -- , - �B0 I <br /> I III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> E OF OWNER CARE OF ADDRESS INFORMATION <br /> 16 <br /> MAILING OR STREET ADDRESS ✓ to ndicete INDIVIDUAL D LOCAL-AGENCY EDSTATE-AGENCY <br /> Pe `°-)09 �-� CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZI PHONE#WITH AREA C DE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if'questions arise. <br /> f TY(TK) HQ F4]_4- -101 5T�J3 <br /> I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED y <br /> ✓ <br /> bo,b it acah, 0 1 SELF-INSURED "' Q GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 7 STATE RIND <br /> (]8 STATE RIND 3 CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 6 CERTIFICATE OF DEPOSIT 0 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: 1.❑ II.❑ Ill. <br /> TH/S FORM HAS BEEN C9l1jMD1<DR PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> l <br /> I TANK OWNER'S NAME(PRINT &SI A TANK OWNER'S TITLE DATE YNEAR <br /> T <br /> J__ <br /> LOCAL AGENCY US <br /> i <br /> I COUNTY# JURISDICTION# FACILITY# <br /> m FTTI 23 11 1 = <br /> F, <br /> LOCATION CODE-OPTIONAL CENSUS TRACT N •OPTIONALSUPVISOR-DISTRICT CODE-OPTIONAL <br /> j <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 /> OWNER MUST FILE THIS FORK THE LOCAL AGENCY IMPLEMENTING THE UNDERGRTORAGE TANK REGULAILON6 <br /> FORM A(6.95) <br />