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STATE OF CALIFORNIA <br /> a <br /> - STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> cwWT?"r MA-V-V- PL- ►JbP-Y-, �vIJu O <br /> ADDRESSNEAREST CROSS STREET PAACELII(OPrIDNAU <br /> 1_71M <br /> � W. ct �* z WYE( F=FLE-i;t10 Nttv <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> Gi rbc+ CA <br /> TOINDI RTE O CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' FEDERALW ENCY' <br /> DISTRICTS' <br /> N ownw of UST Is a public agency,complete the following:name of Supervisor of dlvitbn,taction,w office which operates the UST <br /> TYPE OF BUStNESSX t GAS STATION 0 2 DISTRIBUTOR 0 RE/ IF INDIAN i OF TANKS AT SITE E.P.A. I.0.i lopo") <br /> Q 3 FARM = 4 PROCESSOR 0 5 OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> D V- q S: NAM <br /> T.FIRST) Q PHONE i WITH AREA CQOEE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> N E ! CARE OF ADDRESS INFORMATION <br /> MAILWQ C18 STREFI ADDRE & \ ✓ Owlbindkate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE.AGENCY <br /> 1/O' <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME �T—qt STATE ZIP CO HON i WWSLi AREACOOF <br /> M. TANK OWNER INFORMATION-(MUST BE COMPLETED) `/r/moi Y or <br /> NAME OF OVINER CARE OF ADDRESS INFORMATION <br /> MAILING OR SS RREEETAODRESS ✓ babiMkale 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ,/5a b6dicale 0 1SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE t[--]4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 ExEMPTION O 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I..6?r it.O III.O <br /> THIS FORM HAS BEEN COMPLE D UND NALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE 'S NAME(P TED&S ED4 / OWNER'S TITLE <br /> • . 3.� _ D tv T AY/YEAR <br /> .M. /r�`�J�F/ t <br /> LOCAL AGENCY USE ONLY <br /> COUNTY! JURISDICTION! FACILIT`/! Al <br /> LOCATION CODE -OP77ONAL CENSUS TRACT-OPTIONAL SUPVISOR-DISTRITCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA 1393) FOW833A417 <br />