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0 0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM v <br /> COMPLETE THIS FORM FOR EACH ILrrY/SITE <br /> MARK ONLY Q I NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT Q d AMENDED PERMIT 8 TEMPORARY SITE CLOSURE U <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> G // DO/l S4 i"A�L <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFTIONAU <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> t---scaCA 3k -rq qv Box / <br /> TOINOIC TE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY O FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I—I ' RqS STATION Q 2 DISTRIBUTOR RESV IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(opfianal) <br /> '�T l FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRSn // C2�g p <br /> Zle Am AREA <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE k <br /> VVITH AREA COOP <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> t�L (a.2 ' '7 <br /> MAILING OR STflEET AODRyESS ✓ box biMiwu Q INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 3 YO0 <br /> IV,-�'4-1 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ca l/v 3 Z aq -S- 3d ,-Y// <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> a vri 4 S '27-- <br /> MAILING OR STREET ADDRESS ✓ Oax binakau (] INDIVIDUAL 0 LOCAL AGENCY Q STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ Ks v a a a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biro m, 0 I SELF INSURED (]2 GUARANTEE = 3 IN CE O a SURETY BOND <br /> 0 5 LETTEROFCREOIT O 6 exEMPTION 99 OTHEq <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ACI # <br /> G o W .No�3 <br /> t <br /> CE STRACT# - COO - <br /> M MUST E PANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM ,UNLESS T GE OF SITE INFORMATION ONLY.91) FCRM;A-5 01 <br />