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'�60un f C STATE OF CALIFORNIA r of STATE WATER RESOURCES CONTROL WARD i UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA iy COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F7 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F--] 7 PERMANENTLY CLOSED SITE ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE --- I I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME_ NAME OF OPERATOR �RCO QAC. \RSocN r -ANN ADDRESS \ NEAREST CROSS STREET PARCEL 0 (OPTIONAL) N\ CITY NAME ��es� STATE CITY NAME STATEZIP CODE SITE PHONE x WITH AREA CODE S'Cuc\��o�1 CA as2bq .gStb 'C�oI/ BOX TOINDICATE D CORPORATION I�r INDIVIDUAL PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/IF INDIAN X OF TANKS AT SITE (optional) 3 FARM � 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON fSFCONOeRVI - nntinnai DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE DAYS: NAME (LAAST, FIRST) �20q� 4 �v� -01 �) b c lY Co. H AREA ODE NIGHTS: NAME (LAST, FIRS PHONE 0 W TH AREA CODE c2�q� NIGHTS: NAME (LAST, FIRST) rt $�0 �� MAILING OR STREET ADDRESS N\ IL PROPERTY OWNFR INFORMATION . IMIIST RF rr)MPI FTr:ni NAME CARE OF ADDRESS INFORMATION c lY Co. Ey t S MAILING OR STREET ADDRESS nn II_ p ✓ box bindicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY MAILING OR STREET ADDRESS CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME ��es� STATE ZIP CODE PHONE t1 ITH AREA CODE S�oa III. TANK OWNER INFORMATION - (MUST BE COMPLETEDI NAME OF OWNER F�1 i� Cu CARE OF ADDRESS INFORMATION E 1) S DATE M NT DAYNEAR l�„�a� u rc� c . 7 CENSUS TRACT X -OPTIONAL MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY ['CORPORATION Q PARTNERSHIP 0 COUNT( -AGENCY FEDERAL -AGENCY CITY NAME S STATE ZIP CODE O`l01—�Do3l PHONE x WITH AREA CODE (`vF (o10—NON IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HO 4 F4 I - G (�'❑ V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF.INSURED 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION 0 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: I. = II. = III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME PRINTED 8 SIGNATURE) � f I APPLICANTS TITLE DATE M NT DAYNEAR l�„�a� . � , LOCATION CODE -OPTIONAL CENSUS TRACT X -OPTIONAL LUC:AL AULNUY U51: ONLY i COUmNTY # JURISDICTION # FACILITY # M _ LOCATION CODE -OPTIONAL CENSUS TRACT X -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SlitE INFORMA ION ONLY --, „ k, i J V �- VN CO . ENV . 4ix FOR0033A-5 T \A I- 'P.o.dor, %coli, �vr Tocr Co, . CLS201