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iboo^ e STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA COMPLETE THIS FORM FOR EACH FACIII16171YISITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED ONE ITEM 2 INTERIM PERMIT 0 < AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE �. I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OBA OR FACILITY NAME NAME OF OPERATOR S /n /e If n C SG Ink (Pim ADDRESS NEAREST CROSS STREET PARCEL 0(OPIIONAN S d CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE 701NOCATE ED CORPORATION IN WWAL ED PARTNERSHP E3 LOCAL G Y O COUN ,m;ENCY Q STATEAGENCY Q FFDEMLAGENCY TS TYPE OF BUSINESS 0 T GAS STATION E:] 2 DISTRIBUTORRE SERINNDIIAAN A OF TANKS AT SITE E.P.A. 1.D.s(optiplW) Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS a-- EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE•WITH AREA CODE DAYS:NAME(LAST,FIRST) S _11 1 (.Z r- Gev Da5 -9Y£r — NIGHTS: NAME(LAST,FIRST) PHONEI WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P [AWITH AREA QQQ�_ Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION SLLtu (,� MAILING OR STREET ADDRE ✓ bYdiCNA C:3 INDIVIDUAL ED LOCAL-AGENCY 0 STATE-AGENCY P,, 0/ V K 3A M CORPORATION M PARTNERSHIP C:3 CWNTY-AGENCY 0 FMERALAGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE SlL7c (cJv� t CA 951v/ 9 - 5 yS3� III. TANK OWNER INFORMATION•(MUST BECOMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Sar e u S- T/_ MAILING OR STREET ADDRESS ✓ 5m nvkkala INDIVIDUAL D LOCAL-AGENCY ED STATE-AGENCY CORPORATION I1 PARTNERSHIP (]OOUNTY-AGENCY = FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 p 3 a (p V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ �bMb� �� I SELF-INSURED O 2 GUARANTEE O 3 NSURMCE Z SURETY BOND O 5 LETTER OF CREOT O 6 EXEMPTION Q W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Unless box I or II is gheI CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= IL III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLIOANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY 0 JURISDICTION p FACILITY 1 G EOF'S 7 02577 LOCATION CODE -OPTIONAL CENSUS TRACT$ -OPTAONAL SUPVISOR-DISTRIOTCODE -OPTIONAL -'VD THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 FORM A(5-91)