COMPLIANCE INFO_1989-1998 - Laserfiche WebLink

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t....Cc. STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD d, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE to MARK ONLY E3n 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE . ONE ITEM F'] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I t .-1^ r wrnneuA'r ^K1 o_ AnnOeee _ !tl#I ICT RC rnRMDI 9=nl I. rm%d 11IQ I L all vl unr..I...--. -- — --. __I DBA OR FACILITY NAME NAME OF OPERATOR Waterloo Li uor 'Mr. Heng Chea ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 2512 E. Waterloo Road Filbert Cn`9V!RFkton STATE ZIP CODE SITE PHONE # WITH AREA CODE CA 95205 (209) 463 4114 ✓ BOX Q CORPORATION D INDIVIDUAL PARTNERSHIP LOCAL -AGENCY D COUNTY -AGENCY' (] STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS ' # 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 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 1# OF TANKS AT SITE E. P. A. I. D. # (optional) Q 3 FARM Q 4 PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS three rurlarrNry rnNTAr-T PERSON IPRIMARYI EMERGENCY CONTACT PERSON (SECONDARY) - ontional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE CHER lien 209 463 4114 DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Theresa PELUSO,individ.ually and as Manager f LITTLE BIG HORN TKUST and Nevada Trustees MAILING OR STREET ADDRESS Administrators and Katherine ✓ boxtoindicate ® INDIVIDUAL LOCAL -AGENCY Q STATE -AGENCY J. ELSIIOLZ, as trustee of the Trust knoCan as I] CORPORATION E:1 PARTNERSHIP D COUNTY -AGENCY FEDERAL -AGENCY CITY NAME LITTLE BIG HORN STATE ZIP CODE PHONE # WITH AREA CODE 1636 N. Filbert St. -,1 Ili TANK n11iI�IFR INFOY`tl`AA110N -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTHiDAYNEAR same as II and same as I 1 Proprietor 17 April,98 MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL D LOCAL -AGENCY D STATE -AGENCY CORPORATION PARTNERSHIP D COUNTY -AGENCY D FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND Q 8 STATE FUNDS CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT O 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. D 111.0 1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED & SIGN ATU E TANK OWNER'S TITLE DATE MONTHiDAYNEAR Heng Chea �4 1 Proprietor 17 April,98 LOCAL AGENCY USE ONLY ,/' C COUNTY # JURISDICTION # FACILITY #60g0�p y EE LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR •DISTRICT CODE -OPTIONAL LOCATION CODE -OPTIONAL _r�� A)2 1t)22—)q9 Twe rnm/ uneT ee APPnx.nAU!Er% DV AT 1 CAST H1 IND caner DODUtT ADDI IeeTInN - rnAU R. IINLESS T_WS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUGkORAGE TANK REGULATIONS FORMA (6-95)