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STATE OFCAUFORMA • "`•o•-.. co <br />STATE WATER RESOURCES CONTR O i` t <br />UNDERGROUND STORAGE TANK PERMITA IC 10 - FOR A �a <br />COMPLETE THIS FORM FOR EACH•FACILITYISITE <br />MARK ONLY I_' 1 NEW PERMIT O S RENEWAL PERMIT ER"'S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT O A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I PA!`II ITV/aTC IAICn OAAATIn AI o Ann nen.- ,... ,..-..-,.....-• ---. V <br />OBA OR FACIUTY NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />J BNbiMi[ab Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />Gf'�:..L c" <br />6 � <br />ZIP CODE <br />NAME OF OPERATOR <br />c -ADDRESS <br />]� <br />do <br />NEAREST CROSS STREET <br />PARCELA(OPrpNAO <br />G' (i AA -1 <br />h S. <br />CITY NAME <br />S �G c <br />�C Ly <br />STATE <br />ZIP CODE <br />SITE PHONE A WITH AREA CODE <br />�_. <br />CA <br />5"L C, <br />✓ eox <br />TOINDICATE <br />Q CORPORATION <br />Q INDIVIDUAL Q PARTNERSHP <br />Q LOCAL -AGENCY Q COUNTY.AGENCY <br />Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION Q 2 DISTRIBUTOR/ <br />IF INDIAN <br />A OF TANKS AT SITE <br />E. P. A. L D. s (CWT ) <br />Q ] FARM <br />Q d PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />/ <br />tmtNUtNUT OUN I ACI PtH5014 (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE A WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) PHONE A WITH AREA CODE NIGHTS: NAME (LAST, FIRST) <br />P <br />II. PROPERTY OWNER INFORMATION - (MAST RF OnMPI FTFn) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />J BNbiMi[ab Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE A WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST RF COMPI FTrm <br />NAME OF OWNER - <br />CAREOF ORESS INFORMATION <br />MAILING OR STRE AOORESS <br />✓ c Q INDIVIDUAL Q LOCAL AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL,AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE A WITH AREA CODE <br />IV. OUAMU Lit tuUALILA t IUN Us F STORAGE FEE ACCOUNT NUMBER - Call (916) 323.9555 if questions arise. <br />TY (TK) HO 4 :�- *t ( S <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ Ow e'udlesA Q 1 SELFINSURED Q 2 GUARANTEE 0 3 INSURANCE Q A SURETY BONO <br />Q 5 LETTEROFCREDIT Q B O(ELIPTION Q N 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 />CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. O ILO IN. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST DF MY KNOWLEDGE, IS TRUE AND CORRECT <br />,PPUCANTS NAME (PRINTED b SIGNATURE( APPUCANTS TITLE DATE MONTWDAYIYEAR <br />LVUAL AUtNGT U5t UNLY <br />COUNTY It JURISDICTION x FACILITY # 64,,,,,4b y <br />31`T mL UJ�ZZ <br />LOCATION CODE -OPTIONAL CENSUS TRACTS-OPiIOAML SUPVISOR-DISTRICT CODE -OPTIONAL <br />v/ 23�u z <br />-^THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS ISA LCHANGE OF SITE INFORMATION ONLY. <br />' HJH=A.5 <br />