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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA >, ; COMPLETE THIS FORM FOR EACH FACILITYtSITE NE`N PERMIT J S RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 / $�Y CLOSED 91 TE MARK ONLY --� ONE TEM 2 INTERIM PERMIT a AMENDED PERMIT 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA FACILITY NAM C /jilL, r\ / NAME OF OPE OR . J G 'C/ NEM %CROSS ST EEi PARCEL/IOPTIONAU A DR - CITY.ASTATE ZIP 0006 � - I STE RHONE a WITH AREA CODE /1 CA i �/V7 ✓ 30X CORPORATION 1 INOIVDUAL PARTNEISMP JLOCALA6ENCY COUNTYAGENCY• O STATE-AGENCY- C FEDERAL-AGENCY' TO INDCATE 'j owner d UST is a public agency.CO h see the huht g:name d Supenaw d deiipn,semen,a Mics�icn opaates the UST TYPE OF BUSINESS 1 GAS STATION :� 2 DISTRIBUTOR ✓ IF INOIAN a OF�AT SITE E-P.A. 1.0.s(ganaMU L RESERVATION L 3 FARM s PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional GAYS: NAME(LAST,FIRST) PHONE a WITH AREA CAGE GAYS: NAME(LAST,FIRST) PHONE a wITH AREA CODE ,NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGVHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME I CARE OF ADDRESS INFORMATION n MAILING OR STREET ADDRESS '/�1 w ✓ —e'er INDIVIDUAL LGCALAGFNCY STATE AGENCY I/ I�G^RPOMmm C itAmeRSMP COuNrYAGENCY F:DERALXaERCY CITY NAME t STATE ZIP CODE I PHONE s WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER GRE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ 001 xi = '.IDIVDUAL LOCAL-AGENCY _' STATE AGENCY C'CORPORATION = PARTNERSHIP COUMIGENCY FAERAL AGENCY CITY NAME I STATE ZIP CODE I PHONE s WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HO 77= a 3 Z 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED I SflF:NSURED n 2 WMANTEE 3 INSURANCE I—; s SURETY SOND ✓ ben bineicus ^� c- mpnON `I W OTFER LJ STETTER OFCREdf s VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner un1 box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGALNOTIFICATICNS AND BILLING. 1. It U.JI THIS FORM HAS BEEN COMPLE7ED UNDER PENALTY OF PEFLIURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT OWNERS NAME(PRINTED a SIGNED) OWNER'S TIRE DATE MONTWOAY/YEAR LOCAL AGENCY USE ONLY wv aI CO�x JURISDICTION U�L—J • � FACILITY# LOCATION CODE -LPT(pNAL CENSUS TRACTS -�7N7AWL� SUPVISOR-OISTRIC �IOPJ7-2-) TV THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF WE iWORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IYPLENEIRING THE UNDERGROUND STORAGE TANK REGUU11M FCA=3A-R7 FORM A(Dr9O)