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STATE OF CALIFORNIA �R ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> MARK ONLY 1 NEW PERMIT <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 2 INTERIM PERMIT <br /> rn <br /> ❑ 3 RENEWAL PER � e-,-o• ,• o <br /> ONE ITEM ED5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ❑ A AMENDED PERMIT <br /> I. FACILITY(SITE INFORMATION &ADDRESS-(MUST BE COMPLETO 6 TEMPO SITE CLOSURE <br /> DBA OR FACILITY NAME J <br /> / NAME OF OPERA70R <br /> ADDRESS �•✓! G� <br /> �/- �/do�A •1O NEAREST CROSS B I HhET <br /> VV c� `L.�f/ PARCEL:1(OPTIONAL) <br /> CITY NAME T <br /> 5/AC �� STATE ZIP CODE SITE PHONE X WITH gREA CODE <br /> C f/ , �JNN CA <br /> ✓BOxORATION <br /> TO INDICATE 0 WDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY- <br /> AGENCY' <br /> Bowol USTX;apubeagery,Cmpkle u lolbwC name N senord ONio,seiarN �STRICTS QSTATE-AGENCY' <br /> Q FEDERAL-AGENCY <br /> mce wchemom ' <br /> Ne UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN X OFTANKS AT SITE E P.A. 1.0.40(optional) <br /> 0 3 FARM Q A PROCESSOR 0 5 OTHEROR RESERVATION <br /> NDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST)( //JJ )) E Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> /T./C PHON <br /> L09 fj <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA COOL NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLFTFO) <br /> NAME C/ <br /> To _ r- �� CARE OF ADDRESS INFORMATION <br /> MAILING OR SrRFETADORES �!� H ✓ xna�icP: <br /> �� Q IKDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 2 EY X10 PPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME /1 / ST2t , ZIP CD I PHONE X WITH AREA CODE <br /> /\ L_V/ C� > LO Zo 8"3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> e9r <br /> MAILING OR STREET ADDRESS ✓ W to ndnle Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ORPORATKXI O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME740-G& v j ST 9FE _• ZIP Fa,^� PHONE R WITH AREA CODE <br /> CIV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916)3222-9669 if questions arise. <br /> TY(TK) HQ F474- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> W.to ln0bele 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE [:14 SUREIYBOND =5 LETTEROFCREDR Q B UEMPTION O T STATEFUND <br /> Q 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IIA In.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR'AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE TANK OWNERS TITLE _ MON <br /> TWDAY/Y AR <br /> 5 ltiaer S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# { (F�ASCIIIUTYylk/ <br /> m � �tU--�— <br /> LOCATION CODE -OPTIONAL CENSUS TRACT X .OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(695) <br />