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I <br />STATE OFCALIFORNIA 20 p 11 <br />STATE WATER RESOURCES CONTROL BOARD A -✓CA. F �/'Q �� <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA r ff <br />I. FACILITY/SITE INFORMATION A ADDRFSR. (m]IQT Rc mmi cTcm <br />DBA OR FACILITY NAME <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />-""°""�- <br />MARK ONLY <br />ONE ITEM <br />❑ 1 NEW PERMIT <br />❑ 2 INTERIM PERMIT <br />3 RENEWAL PERMIT <br />❑ ❑ 5 CHANGE OF INFORMATION <br />❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />7 PERMANENT Y C ITE <br />�% <br />I. FACILITY/SITE INFORMATION A ADDRFSR. (m]IQT Rc mmi cTcm <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />OL <br />9 <br />A DRESS <br />aeEH, <br />L <br />NEARESTCROSS STREET <br />PARCELp(OPrpggp <br />OGLYOle <br />CITY NAME <br />` <br />STATE ZIP CODE <br />SITE PHONE # WITH ARA CODE <br />✓ <br />CA 953 7 <br />- Zio <br />Box <br />TOINDICATE <br />LeyORPORATION <br />0 INDIVIDUAL [__1 PARTNERSHIP <br />0 LOCAL -AGENCY 0 COUNTY -AGENCY <br />STATE <br />DISTRICTS <br />-AGENCY 0FEDERAL-AGENCY <br />TYPE OF BUSINESS <br />❑ 1 GAS STATION ❑ 2 DISTRIBUTOR= <br />IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # jet tign I <br />RESERVATION <br />❑ 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br />NAME (LAST, FIRSTD PHONE # WITH A <br />Q <br />NAME <br />EMERGENCY CONTACT PERSON <br />NAME QAST. F1FtSn r_ <br />CARE OF <br />CA <br />LJ INDIVIDUAL O LOCAL AGENCY 0 pTE AGDICY <br />.,L7f9X 9 ]CORPORATION 0 PARTNERSHIP 0 COUNTY#GENCY FEDERAL -AGENCY <br />UE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETEDI <br />ADDRESS <br />LJ INDIVIDUAL O LOCAL -AGENCY <br />O PARTNERSHIP 0 COUNTY -AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HO LZ�- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box le indicate P-1 SELF INSURED E-1 2 GUARANTEE O 3 INSURANCE EI d SURETY BOND <br />5 LETTEROFCREDIT EJ 6 EXEMPTION I_] 69 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or 11 is c cked. <br />CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. 11 <br />II.❑ I Illi <br />THIS FORM HAS BEEN COMPLL�F(. UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE <br />1 �� <br />�. �'I o� 9 <br />LOCAL AGENCY SE NL !0. 3y� /6 r <br />3 COUNTY# ' / �-# JURISDICTION at !-a1, �yOv FACILITY A r�N`Or��tt / <br />LOCATION C E OPTIONAL CENSUS TRACT -OPTIONAL (L�ISUPVISOR -DI RICT CODE -OPTIONAL <br />63 JV( D� D� <br />THIS FORM UST BE ACCOMPANIED BY ATL AST (1) OR MORE PE IT APPLICATION • FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMA1 ION ONLY. <br />FORM A(129n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />Il go 0 FOROMA-116 <br />