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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBP OR FACILITY NAME 7y NAME OF OPERATOR ADDRESS NEA EST CROSS STREET PARCEL#(OPRONAU S"LD S. G6-f/ICi— APFvmm� uq CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Looms CA 0ra 331- 7f-277 ✓BOX F-1 CORPORATION 0 INDMDUAL O PARTNERSHIP E:3 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY- = FEDERAL-AGENCY- TO INDICATE DISTRICTS 'Noem#r o1 UST u e P9)k82ercY,CDrMWN the blbwYiq name d stpery r d drv'sidl,swim m dke Och WMes the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(aptbneO 3 FARM d PROCESSOR 5 OTHER RESERVATION ❑ ❑ OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS NAME( T,FlRSn pp\\HO'N}E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION L .A.- S. a- MNUNGORSTREET ADDRESS. / ✓ boa to IrdwoQ#JDNIfXIAL -AGENCY STATE-AGENCY l!/,l!/,2f !/, GnET'#�Fj STT O CORPORATION O PARMERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY E STATE ZIP CODE I PHONE#WITH AREA CODE o0= G4 "l 2> &Dj 331- 7f7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION S. D- MAILING ORSTREET ADDRESS p.� ✓ Owlo ndnta CD WDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY Sf- GY• COWORATKIN ED PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE G� a- 95 a -7x-27 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 R questions arise. TY(TK) HQ 4 4- - O V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bos b hftft O 1 SELF'NSIIRED =2 GUARANTEE O 3 INSURANCE O A SURETYBOND Q 5 LETTEROFCRmIT O 6 EXEMPTION O 7 STATE RIND 8 STATE RIND B CHIEF FINANCIAL OFFICER LETTER OBSTATE RIND&CER nFICATE OF DEPOSIT = f0 LOCAL GOVT.MECHANISM O ##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 INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANID16ORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHYDAYIYEAR LOCAL AGENCY USE ONLY COU�l NTY# JURISDICTION # FACILITY# ILITY m LOCATIONCODE -OP77ONAL CENSUS T CT# -OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL 4>z- z5 .14v 3zv THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(e-96) OWNER MUST FILE THIS FO' 'NRH THE LOCAL AGENCY IMPLEMENTING THE UNDERGP^'IND STORAGE TANK REGULATIONS �/