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OVMClS STATE OF CALIFORNIA r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY EI 1 NEW PERMIT F-1 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED i TE ONE ITEM E 2 INTERIM PERMIT Q 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE I"I( i earn ITVICITC IAICnCIUTATInM E AnnGGC¢ _ tRRIICT RF rr1AAPl FTFnl DBA OR FACILITY NAME NAME OF OPERATOR Waterloo Liquor sir. Heng Chea ADDRE2.5f , E.e Waterloo Road N�Fi ert ROSS STREET PARCEL #(OPTIONAL) CIT9t1&ftton STATE ZIP CODE SITE PHONE # WITH AREA CODE ZIP CODE CA 195205 (909) 461 411_4 1 ✓ BOX CORPORATION (] INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY ED COUNTY-AGENCY0 STATE -AGENCY' FEDERAL -AGENCY' TO INDICATE DISTRICTS ' 8 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 i GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN # OF TANKS AT SITE E.P.A. I. D. # (optional) 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR RESERVATION 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 CEA,Heng (209) 463 4114 ✓ boxto utd..to 0 INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE If WITH AREA CODE :HEA Hen(209) 473 2831 STATE Ica "'Al. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NA �ieresa PELUSO,individually and as Manager CARE OF ADDRESS INFORMATION 31 LITTLE BIG HORN TRUST and Nevada Trustees MAILING OR STREET ADDRESS n s ra ors -a-575 KatherIne ✓ boxto utd..to 0 INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY J. ELSHOLZ, as trustee of the Trstat known as 0 CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME LITTLE BIG HORN 1636 N. Filbert St. STATE Ica ZIP CODE PHONE # WITH AREA CODE ZIP CODE PHONE If WITH AREA CODE III, TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER' CARE OF ADDRESS INFORMATION same as II and same as I C:ea MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY 0 CORPORATION (] PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4 -j V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE = 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION = 7 STATE FUND 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND & CERTIFICATE OF DEPOSIT 0 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. r7 if. [�:] III. O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER' NAME (PRINTED & SIGNA E' Heng TANK OWNER'S TITLE DATE MONTHIDAYNEAR C:ea Proprietor 17 April,98 LOCAL AGENCY USE ONLY C - COUNTY # JURISDICTION If FACILITY m -9 < k I i I LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT L� (1) OR MORE PERMIT APPLICATION - FORM B, UNLESSS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLIWORAGE TANK REGULATIONS FORMA (6-95) Imo. -- nd