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IS SO <br /> STATE OF CAUFORNIA <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE In <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT F-1 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT F--] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /-:7'/l /k OA3 7 S96 <br /> DBA ORF U NAME I� � NAME OF OPERATOR <br /> NEAREST_ OSS FEET PARCEL (OPTIONAL) <br /> CITY NAME r STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> G �`✓ CA �-�o Z2V03 e3 S <br /> ✓ BOX _aj�pRPORAnON M WDMOl1AL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' ED STATE-AGENCY- O FEDERAL-AGENCY' <br /> TO INDICATE <br /> p owmrd USTuapublicegnq•mnpWta 9la bMwin¢time d sopervb"ofO ejon.sedioo or d5pe w Ich opemtu the UST <br /> F INDIAN TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR = RE EIRVATION »OF TANKS AT SITE E.P.A/ I.D.N(optianaQ <br /> 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS C/� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE Y TF7 AREA CO E <br /> z� 5 ?,Zo a r <br /> NIGHTS: NAR ST FIR PHONEY WITH AREA CODE NIGHTS: NA , 'RST) PHONE a WITH AREA CODE <br /> Co /f�� T) mac( <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME T _ .�G CARE OF ADDRESS INFORMATION <br /> MAILING OR STRE ADDRESS ✓ b0xb^drale Q NDIVIOUAL O LOCAL AGENCY Q STATE-AGENCY <br /> " -91CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAME 7c— / A STATE /J ZIP C7��Q� PHONE N WITH ,9 CODE <br /> 6 1; Ij <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) L� 2.02 /71 <br /> NAME OFF OWN` / � ACARE OF ADDRESS INFORMATION <br /> © <br /> MAID RSEETADDRESS ✓ b to^6mla O WDIVIWAL O LOCAL-AGENCY O STATE-AGENCY <br /> `` �Q 0WORATION Q PARTNERSHIP l�COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ^�� i� - ZIP CO E Q PHONE/�TH AREA.D�D�5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3222--9669 if questions arise. ClY <br /> TY(TK) HO 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 10 hkate 1 SELF-WSURED O 2 GUARANTEE3INSURANCE Md SURETY BOND O 5 LETTER OF CREDIT O 6 EXEMPTION O 7 STATEFUND <br /> D 9 STATE FUMA CHIEF FINANCIALOFFICER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCMGOVT.MECHMIISM O 99 OTHER <br /> - <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or11is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II.l`X III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED B SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> G <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION# FACILITY N <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N -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 WrTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A 10.051 161 <br />