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60u" of C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W �� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT [_] 6 TEMPORARY SITE CLOSURE 4)z /C; -T I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 'E'T N C /"IIki qr—% - /V-- 6e MIS S:r kli�vG.y P• k�e ADDRESS_ _ NEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE Q COUNTY -AGENCY 0 FEDERAL -AGENCY R 53 A t�'3 3 - 311,E ✓ BOX TO INDICATE D CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY-AGENCY0STATE-AGENCYFEDERAL-AGENCY' DISTRICTS' If owner of UST Is a public agency, complete the following: name of upervisor of division, section, or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 1# OF TANKS AT SITE E. P. A. I. D. # (optional) 0 3 FARM 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PFRSON ISFCnNnAm . _ft„„nt DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE S�,16H X14%v Zit 83 -3 �` DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE /tL J_061N4b-ff2 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE p,4P_7 —.e -OTT 11. PROPERTY OWNER INFORMATION - (MIIST RF rOMPI FTFm NA,yg "i 111. CARE OF ADDRESS INFORMATION FS 1rCA C -S O /� �G p,4P_7 —.e -OTT AIL NG UR ST EET AD ESS ✓ box b Indicate IND ID AL OLOCAL-AGENCY STATE -AGENCY L �+ / f >- CORPORATION 0 PARTNERSHIP Q COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME ST TE ZIP CODE FEDERAL -AGENCY PHONE # WITH AREA CODE �t01,0,7/"'20) ZIP CODE PHONE # WITH AREA CODE 9-3.5"- _3113- 13 III. TANK OWNER INFORMATION - (MUST BE COMPLFTFI)1 NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTWDAYNEAR .SA>/l/Ivf 1 /Arty, 0&C'q I� p,4P_7 —.e MAILING O D E �OP'E�IK Ty qty rN V`V I/box b indicate INDIVIDUAL 0LOCAL-AGENCY STATE -AGENCY = CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. t3UAMU OF EQUALIZATION UST 5TORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box ID indicate (] 1 SELF-INSURED 2 GUARANTEE��( L 3 INSURANCE/ i� 4 SURETY BOND 0 5 LETTEROFCREDIT (� 6 EXEMPTION 1-711 99 OTHER AND / /] 0I1 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. �r 11 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR .SA>/l/Ivf 1 /Arty, 0&C'q I� p,4P_7 —.e LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # m LOCATION CODE - OPTIONAL I CENSUS TRACT # -OPTIONAL 3UPVISOR - DISTRICT CODE - OPTIONAL / I HI5 1-UHM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM 0, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA (3193) FOR0033A-17