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STATEOFCAUFORMA <br /> ' STATE WATER RESOURCES CONTROL BOARD ; <br /> 1Q UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM Aar <br /> �. <br /> (Vf� r3Tr,[. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> °•t�I°nM'• <br /> F�MARKONLYED �" Y O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM D 2 INTERIM PERMIT ED 4 AMENDED PERMIT <br /> Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED <br /> DSA OR FACILITY NAME n ) ID +rv-n <br /> Oplc� <br /> -r- <br /> NAME OF OPERATOR 1 <br /> ADDES / Q 2 <br /> I�JO5� <br /> GY. PTONAL) <br /> . NEARE TCROSS TREET PARCELI(OI <br /> I0f <br /> CITY NAME <br /> 0O— �STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> cA SZyo <br /> I/Box S <br /> TOINDICATE CORPORATION M INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O COUNTY.AGENCY' O STATE-AGENCY' (� FEDERALAGENCY- <br /> N owner d UST is a PubSc agency,m"O the Idlowm <br /> ing:name of Supervisor of d"lon,section,DISTRICTS'office whbh operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OFT KS AT SITE E.P.A. I.D.a Tgofionap <br /> 3 FARM O 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIpST) I / PHONE a WITH Aq�A CODE DAYS: NAME(LAST,FIRST) <br /> C��/71 F�/wl N1 �A�/y!�1)7 Uq 13 -- 67[ PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE!WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> G/1-� CARE OF ADDRESS INFORMATION <br /> f [i0A7T <br /> MAILING OR STREET ADDRESS ✓ bos bb#bn 0 INDIVIDUAL L�LOCALAGENCY 0 STATE-AGENCY <br /> PL ez—:- 57— O CORPORATION E-1 PARTNERSHIP O COUAGENCY O FEDERAL AGENCY <br /> CITY NAME STA 21P CODE <br /> 60°� PHONE a WITH AR CODE <br /> � 95 0 33 - 5-63 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �i/ O� GOvs <br /> MAILING OR STREET ADDRESS ✓ hos bVldkaM INDIVIDUAL LOCAL AGENCY <br /> STATE AGENCY2 W, / I — CORPORATION PTNERSHP <br /> CITY NAME � CGLIWYAGENCY <br /> L-1 FEDEMLAGENCY <br /> STATE ZIP CODE PHONE <br /> a WITH AR ACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boo blMicee 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> O 5 LETTER OF CREDIT =6 EXEMPTION 0 99 OTHER <br /> O s SURETYBOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[1] II.� III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> # FACILITY-37-5 <br /> � D <br /> I`Gi`IT�I'I J <br /> LOCATgN CODE -OPTIONAL CENSUS TRACT! OPTIONAL 91�VISOR-DISTRICT CODE -fW71t3A4LL <br /> ®L 37,b l�J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3M3) <br /> igi0al]AIL7 <br />