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MIR I m STATE OF CALIFORNIA - �.��'"�"' °+. _ STATE WATER RESOURCES CONTROL BOARD r r 1:. UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA e COMPLETE THIS FORM FOR EACH FACILITY/SITE ld ' MARK ONLY ❑ I NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR T!/ > �4T L r �.Q.:D� ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) 5PCs W 940. �! CITY NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE f ii CA 9100 2if7,> ✓Box O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS Gov roi USTL apubkageng•wmplelaMlullowng re d supeMwrol dMsion,section oroffm which operates the UST TYPEOFBUSINESS ❑ I GASSTATION ❑ 2 DISTRIBUTOR ❑ RE61IFINTDIAN ION MOFTANKS AT SITE E.P.A. I.D.&Wficnao ❑ 3 FARM ❑ 6 PROCESSOR 5 OTHER OR TRUST LANDS J ( — DO/&,_�5 y EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,�s11RSn PHONE a WITH AREA CODE�y�� DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STRE ADDRESS ✓ box to hdcale DMDUAL Q 0 LOCAL-AGENCY STATE-AGENCY O$ G —r- 0 CORPOMTIOIPARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITU AME STATE ZIP CODE Z HONE#WITH AREA CODE �co! Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ baxtobldOste Q INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY pd e O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONEII WITH AREA CODE G A gyz�v IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indeate 1 SELF-INSURED Q 2 GUARANTEE 0 S INSURANCE =a SURETY BOND 0 5 LETrEROFCREDTr =6 EXEMPTION =7 STATE FUND � 3STATE FUND&CHIEF FINANCIAL OFFICER LETrER O9STATE FUND&CERTIFICATEOFDEPOSR O10LOCAL GOVT MECHANISM O99OTHER 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 TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY N JURISDICTION k FACILITY M �. ® 161DIT91inbl 3(e9 LOCATION CODE -OPTIONAL CENj_SSUS TRACT M -OPTIONAL SI Vr ;-DISTRICT CODE -OPTIONAL 44111 Q� C7 Z- 3i= cr THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS F0FjW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR ff STORAGE TANK REGULATIONS