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J STATE OF CAUFORMA w� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE °•�„a..,• MARK ONLY ❑ f NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ d TEMPORARY SITE CLOSURE I. FACILfTY/SITE INFORMATION S ADDRESS-(MUST BE COMPLETED) 11RA 09 FAdLITYN M � / C.� ...J NAME OF OPERATOR comp ADDRESS S CROSS STREET PARCEL#(OPTIONAU F . r o �o( w 09-0 a OQO CITY NAME STATEPCODE SITEP NE ITH AREA CODE v Box c ca (,y- TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP CD LOCAL-AGENCY COUNTY AGENCY' O STATE- GF11C)• O FEDERALSGENCY' DISTRICTS' If owner of UST u a Public agency,corTpale the IOYoring:nanr of Supem”of IIN4bn,section,w ohim which ttperatee the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR fGCICSfO v RESERVATIONDDIAN A OF TANKS AT SITE E.P.A. I.D.a(gwlmal) ❑ 3 FARM ❑ a PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY NAME(LAST.F RST mn �D PHON� ITH AREA CODE D S: NAME(IAST,FIRST) �O PTE` WITH AREA CODE -Jqj NIGHTS: NAME(LAST,FIRST) r-"l NE a WITTOIH AREA COD/DE N TS: NAME T, (RST) PHONE la WITH AREA CODE dfmcp b - 36 6J 333-a 3 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAM!E—/ •) S CC C Ch-) n� CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ih ,{— ✓ Eos binaicNa = INDIVIDUAL = LOCAL AGENCY 0 STATE AGENCY 3 - ' 1 S I - O CORPORATION PARTNERSHIP 0 COUNTY AGENCY 0 FEDERALAGENCY i CRY N ME 0 G STATE LP CODE PHONE a WITH AREA CODE -�� c S C _ 1oG-LL III. TANK OWNER INFORMATION-(MUST BE COMPLETED) (S/0 -J _)o 5` NAMEOF OWNER CAR OFA OPESS INFOR .4TION L //Yw r / AILING O/R STRE ADDRESS ✓ =10,10,00 0 INDIVIDUAL LOCAL STATE AGENCY CITY 66hj,0,4� (]CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY FEM-1 AGENCY S TE 21P E PHONE a WITH AREA CODE � -k sao 15 - LI IV.BOARD OF EOUA IZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions aril. TY(TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Eos bltwbala t SELF-INSURED _1K.2 GUARANTEE 3 INSURANCE O a SURETY BOND 5 LETTER OF CREDIT 0 6 EXEMPTION O a1 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 LNDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNE I OWNE TITLE DATE MONTHADAYNEAR H G¢r. L&C Nv�,�L4,1 . �Itc(ti, �I ✓ ,a - A4 1124 LOCAL A ENCY USE ONLY COUNTY 0 JURISDICTION x FACILITY TlV36 f7 $T 7FF ZyRl , LOCATION CODE -OP7?OAAk CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE "4 INFORMAT/IO�N 0 Y OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS � o q I I" FORM A(193) -