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STATEOFCAUFOFKA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> II COMPLETE THIS FORM FORE CILR7I <br /> II�� SITE <br /> MARK ONLY iJ I NEW PERMIT F 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM S1TE <br /> ONE ITEM F 2 INTERIM PERMIT F1 4 AMENDED PERMIT [e'FEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME l..�l..i /J NAM PER TOO <br /> �I 0.�. <br /> ADDRESS EST CROSS STREWr CELO(OPfgNAL) <br /> R <br /> O,1114 1145T. <br /> CITY NASTATE <br /> ME S PHONE#WITHAREACODE <br /> CA ip <br /> TO INDICATEOORPORATIO C::]INDIVIDUAL O PARTNERSHP LOCALAGENCYCOUNTYAGENCY' O STATE- ENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'N owner ol UST is a public agency,wrrplele the Idlowkw p:neno(Supervisor of cNMbn,sactbn,w office which 4.the UST <br /> TYPE OF BUSINESS LG GAS STATION = 2 DISTRIBUTOR D RES RVINIAN ATION a OF T I(S AT SITE E.P.A. I.D.a(apfMrW) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUPTLANDSVq <br /> EMERGENCY CONTACT PERSON (PRIMARY) MERGENCY CONTACT P RSO (SECONDARY)-optional <br /> DAYANAME(LAST,FI n PHONE i WITH AREA CODE N T,FIRS PHONE a WITH AREA CODE <br /> e d sIG � 5ry Y4i SL� �� <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAM T,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM hg, (z-yJJ Q CARE <br /> MAI STREE DRESS ✓ bED INDIVIDUAL <br /> L 1 LOCALAGENCY =1 STATEMENCY <br /> 12-WPOR1TION <br /> ED PARTNERSHIP I1 COUNTYAGENCY I—] FEDERAL1DENCY <br /> CITY 9 2M CODE PILONE� THAREACODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW CARE D RE INFORMA N <br /> S-A 4 � <br /> MAILING OR STR DRESS ✓�I�w�bYMbAG <br /> sM = INDIVIDUAL Q LOCAL-AGENCY El STATE-AGENCY <br /> �„) �C G XIM11PORATION O PARTNERSHIP O COUNTY AGENCY D FEDERAL-AGENCY <br /> CIT'NAME ST TE ZIP CODE PHONE a WITH AREA CODE <br /> sem,- 4 �sff 3 s/ - y-2 <br /> IV.BOARD OF EQUALIZATION UST STOR E FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 414--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ <br /> but lrMkals O 1 SELF-INSURED O 2 GUARANTEE URANCE D 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION O N 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L.Q/ ILD III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> O E NAME(PR �ED`BXEO) OWNE '9 TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYY / - , I ne,/\ JURISDICTION� + FACILITY t L <br /> �7 /G 7 <br /> Lv <br /> LOCATION 60DE -OPTIO L CEENNSUSOSA_TAWTO^OOPTTIIONAL 9UPV190R DISTRICT -OPTgNAL <br /> V <br /> THIS FORM MUST BE ACCOMPANIED BY A LAST(1)OR MORE PERMIT APPLICATION- FO M r U ESS THIS IS A CHANGE OF SITE IIgOWTION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/83) FCROOJ3AA7 <br />