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aOVs 11.000 STATEOFCAUFORNA •° `� STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATI PLETE THIS FORM FOR EACHFACILITYSITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] E M CLOSED SITE �E� 4 Aim" p ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ; DRAOR FACILITY NAME NAME OF OPERATOR D ,E[Ec c :5/4W 6oxi7 sIVAVJE ADDRESS NEAREST CROSS STREET PARCFLA(OPIIOtMU i 7' 040A F9 aO87- 16o -o ,6 CITY NAME STATE ZIP CODE SITE P STDCKTaA/ CA 6.ziLf ROf i o ✓ BOX TOINDICATE FeSRPORATION 0 INDIVIDUAL =PARTNERSHIP DISTRICLOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' EDFEDERALAGENCY' 'X owner d UST Is a public agency,co plate the blowing:none of Supervbor of division,section,or office which operates the UST TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR q SVIFE RVATOION s OF TANKS AT SITE E.P.A. 1.DD.t(apgael) 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS CAD 78,z,660 634 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE « on/ zo i o c AJ 0 X0 9, a7 0 86 0 NIGHTS: NAME(LAST.FIRst PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE sr+sl,E 20 77A /009 ;4o 19 OIL 2 If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMEhR�i CARE OF ADDRESS INFORMATION MAILINGINSSTREETT ADDRESS ✓ box biM4ale INDIVIDUAL =1 LOCAL-AGENCY [:1 STATE AGENCY /-0 AVOX S7 0 0 CORPORATION [-] PARTNERSHIP COUNTY-AGENCY 0 FFDERALAGEWY CITY NACODE STiA=k 7-D-0g�{�TE Zps,7-/ RlP CODE of W98/0866 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ��✓/bbmtindimm DIVIDUAL f� LOCAL AGENCY Q STATE-AGENCY LioI POMTION = PARTNERSHIP COUNTY-AGENCY Q FEDEMLAGENCY CIT'NAME STATE ZIP CODE PHWAREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - O D V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bM Io9dbals 1 SELF INSURED 0 2 GUARANTEE I� 3 INSURANCE 0 4 SURETY BOND 0 5 LETrEROFCREUIT a EXEMPTION O 99 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.= II1.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR turf- Bis Ft? tsE H1 /-Ax-77 LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a )r2 ® Fm LOCATION CODE -OPTIONALCENSUSTRACTa -OPTIONAL SUPVISOR-DISTI KFJ DE -OP NAL DO THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANKREGULATIONS FORM Al3931 _ �� 9 � 33 �� FORD037AA]