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t ..- _ . ,+„8 `7t''^'*•��"y"'a4a 1'��' " i' . 'C,,OURCC' c0 STATE OF CALIFORNIA �� 1 STATE WATER RESOURCES CONTROL BOARD W dam, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ao COMPLETE THIS FORM FOR EACH FACILITY/SITE t:1 • C�I,iOR N,r MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED. SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (Oil I FArtl ITV/sITE INFORMATION & ADDRESS - (MUST BE COMPLETED) OBF(�F,ACILITY NAME a3.9,60 NAME OF OPE TOR N �B, 07e'14 1levlt7n S+a+Ion e -74h ADDRESS 'g 5a51 Igor-�h VVY 53 NEAREST CROSS STREET Near Collier f1k PARCEL # (OPTIONAL) CITY NA E STATE ZIP CODE SITE PHONE # WITH AREA CODE Ca rn o CA 0 - 1740 ✓ BOX Q CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' FEDERAL -AGENCY' TO INDICATE DISTRICTS N 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 Q 2 DISTRIBUTOR ✓ IF INDIAN RESERVATION 1# OF TANKS AT SITE I E. P. A. I. D. # (optional) 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODEAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE G -E i5 T14 Zoq- 3 1740 —I!9 c3lev,ron mCixn4er)ar CA_-' 600- 435-;�"62 8 NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE �xErs T1� zcaq-3' 3- 11'.55' hev��r, m1 -r enc �)�rrrrnd on -231-068 II_ PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NA,Mg V1C�`Gr' ",�+�� In ��u +' CARE OF ADDRESS INFORMATION MAILII G OR STRIEET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL -AGENCY Q STATE -AGENCY r = CORPORATION Q PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY CITY v I STATE L'A ZIP CODE 1 94S 4V'_" PHONE # WITH AREA CODE 111 TAAIIC nWIVGR IN=r1RMATItIM .IMIIST RF rOMPLFTEDI M�j O_F OWNER f L CAR ADDRESS 1 ION T�P1mI DATE MONTHiDAYNEAR t"t!v e'0n fiu T5 ►�^+ Gin r MAILING OR STRW ADDRESS ✓ box to indicate E�] INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY U [;;l,EORPORATION = PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY CITY NAMESTATE : ZIP CODE PHONE # WITH AREA CODE n G m�Y� 0 94583 1C)- 2...1 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 It questions arise. TY (TK) HO M44- - A 1 1 Til3d V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate [] 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT O 6 EXEMPTION = 7 STATE FUND 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM = 99 OTHER ======Z=___ VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. D 11. � III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NA E (PRINTED & SIGNATURE) TANK OWNER'S TITLE _ DATE MONTHiDAYNEAR �.lcc. -nTIe;)d_ Asst, -fly rnI 51t. LOCAL AGENCY USE ONLY U COUNTY # JURISDICTION # FACILITY # LOCATION CODE -OPTIONAL CENSUS Tco�ACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT L 1..(1) OR MORE PERMIT APPLICATION - FORM B, UNLESSMIS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU TORAGE TANK REGULATIONS FORM A (8.95)