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• STATE OF CALIFORNIA °+. <br /> STATE WATER RESOURCES CONTROL BOARD d� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A _ , a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE :d <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> hlrJ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> -7T - G2-02.0—o00/ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> j,001__ CA 9s7Ao Z09- 0 <br /> ✓BOXCORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY (]COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> H ownerd UST6 apublb agenry,mmpote the folbwb¢re ofsuperveord Srvison,s onorotFue ichopomtesohe UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORO .1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#tloptionaO <br /> RESERVATION /f <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS [— <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Zs <br /> NIGHT : NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME( ST,FIRST) PHONE#WITH AREA CODE <br /> SI S roq- -1-1-tf I 140v 9LS - 766- 3( <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME 1 r CARE OF ADDRESS INFORMATION\ C --4 <br /> MAILING OR STREET ADDRESS ✓ boxlomd to O INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> (7 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> G./�. � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,- <br /> ��rr <br /> MAILING OR STREET ADDRESS ✓ EntordmY a 2!.WDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY ' <br /> _ A O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> GPS SZ - 3 - -7'1rD <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> T6(94 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxro#goeteT2g.JSELF-INSURED O 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT C3 s ExEmmoN O T STATEFUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 B STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 88 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.& III. <br /> THIS FORM HAS BEEN CO PLETED U DER PENIn I�Y OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRIN TURE TANK OWNER'S TITLE DATE MONT AWYEAR <br /> VI&F- � V <br /> LOCAL AGENCY U NLY <br /> COUNTY x V JURISDICTION# FACILITY# 77i� <br /> m 3 ( -L 10 16 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE IIWORMAtION ONLY. <br /> OWNER MUST FILE THIS FOR JW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(fSTORAGE TANK REGULATIONS <br /> FORMA(8-95) <br />