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STATE OF CALIFORNIA �'e5 s mot STATE WATER RESOURCES CONTROL BOARD 'g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA =� � . . COMPLETE THIS FORM FOR EACH FACILITYISiTE MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ED 4 AMENDED PERMIT fi TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 71M( Ti��, _k P�fA2Pt O[. P�,p,d ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) C> 22 Fkor-rr^ et- P'0 JACK Tc,,� 2 p 7-61— o Z o — 04- clTv NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE k�-I eo Ca Z©i— SqR_ Z I I I ✓ BOX []CORPORATION INDIVIDUAL 0"PARTNERSHIP [] LOCAL-AGENCY 71 COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS `N owner of UST is a public agancy,complete the following:name of supervisorof division,section or office which operates the UST F—T Pf OF BUSINESS � 1 GAS STATION 2 DISTRIBUTOR ✓IF{NDIAN #OF TANKS AT SITE E.P.A- L 0.#(optional) 3 FARM 4 PROCESSOR 5 OTH>=R RESERVATION ',�.,+. CA t- 000 1 5(e D D OR TRUST LANDS -- �► EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 5 I Pyo i'J r T7 V Ne�t ) !-i r,2 v 1►'ti Z aq- S - r l 2 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL [] LOCAL-AGENCY Q STATE-AGENCY '7 (,r�s,0 M(C I"f(;;L L E C_F 0 CORPORATION Dj�'PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE Nt &o- 8(7q - 165"T III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 51-)ME r __ MAILING OR STREET ADDRESS ✓ box io indicate ® INDIVIDUAL OLOCAL-AGENCY QSTATE-AGENCY =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- -I fJ 10 lz 14 19 15 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate Q 1 SELF.INSURED 0.2 GUARANTEE C::] 3 INSURANCE 0 4 SURETY BOND E__1 5 LETTER OF CREDIT 0 6 EXEMPTION 1�7 STATE FUND (]6 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER L__1 9 STATE RIND 6 CERTIFICATE OF DEPOSIT E] 10 LOCAL GOVT.MECHANISM = 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: 1.F—] II,t—'-.1 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED,$S3 N TUR } TANK OWNER'S TITLE �70t DATE MONTH/DAY/YEAR ear IkA 1g qIMC14 LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# FACILITY# ) 7Y7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOH-DISTRICT GODS -©PT7t7NAL 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 TANK REGULATIONS FORM A(6-95)