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STATE OF CALIFORNIA V <br /> STATE WATER RESOURCES CONTROL BOARD «•«ou,c•« <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FO o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ® I NEW PERMIT <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION CLO <br /> ❑ p AMENDED PERMIT El ❑ T PERMANENTLY CLOS ONSITE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLE7O 6 TEMPORARY SITE CLOSURE <br /> ABILITY E <br /> NAME° ATC <br /> S. N RESTCR ST EET/? <br /> CITY ME J V/ PARCELI'(OPTION4y <br /> r <br /> STATE 0Of— <br /> CA SITE PHON M EA CODE <br /> ✓BO% �CORPOgg710N pp v <br /> TO INDICATE I�INDNIWAL (]PARTNERSHIP <br /> ' <br /> If owneraf UST Is, ubrag l LOCAL-AGENCY f3 COUNTY-AGENCY' <br /> D gang,m�nplele Me/albwnff noing dsMe"jWcldwivbn,seulonoro#wewhihoDISTRICTSUST STATE-AG Y' FEDERAL-AGENCY' <br /> TYPE OF BUSINESS ❑ <br /> 1 GAS STATION ❑ p DISTRIBUTOR <br /> ❑ 3 FARMED ROCESSOR ✓ INDIAN #OF TANKS qT SITE #(optional) <br /> ❑ 4 P5 OTHER RESERR VATION E.P.A. I.D. <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS Z� <br /> ° ME(LAST. STI, EMERGENCY CONTACT PERSON (SECONDARY)- <br /> `�J PHO E# AREA C.OpS DAYS: NAME(LAST,FIRST) ) optional <br /> S: NAME(LAST,FIpS Q (/OBD/ L� PHONE#WITH AREA CODE <br /> ^ 7 PH WI A EA OnDE <br /> CIV+ Qf/ 4t.0NIGHTS: NAME(LAST,FIRS-0 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLET <br /> NAA7E <br /> •�J/ �p � <br /> MCARE OF ADDRESS INFORMATION <br /> E <br /> I�ILINC, � ADDRESS � G- <br /> Jl V(l l/�_.) ✓ box to ibirate <br /> ' ED CORPORATION NDIVIOUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CITY AME • — f�PAgTNEASHIP f� wry-AGENCY STA 0 FEDERAL-AGENCY <br /> #WITH_4Q6ACQOE <br /> / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> WN <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR TREET ADDRESS <br /> ✓ boxtobdbate <br /> womouuQLOCAL-AGENCY O STATE-AGENCY <br /> CI NAME r sO CORPORATIONED PARTNERSHIP Q COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> d � <br /> IV.BOARD 0 OUALIZATION UST STORAGE FEE ACCOUNT NUMBER/-Call(916)322.9669 if questions arise. <br /> TY(TK) NO M44- -� MAY 04 1999 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)–IDENTIFYTHEMETHODS rr I IMENTAL HEALTH <br /> ✓box bin6oY 0 r SELF-INSURED _ 2 GUNMNTEE Q 31NSUgANCE Q A SURETY BOND O !UAIT / SERVICES <br /> O B STATE FUND A CH'E ':RX A OFFICER LETTER 0 9 STATE F ND&CERTIFICATE OF DEPOSIT Cq 09 LOCAL GO C:1 6 EXEMPTION IC _JOTHER_STE FUND <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 /> `x­sm ARNG WHICHABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS D BILLING: <br /> I.❑ II.LN III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY RJ .,d <br /> /�- 7-OF MY KNOWLEDGE,IS 7RUEAND CORRECT <br /> OW R'S ME(PRINTED&SIG RE �j <br /> TANK O�WwNER'S TITLE DATEMONTH/DAVNEAR <br /> v <br /> LOCAL AGENCY USE 0 Y 'ems J`— — F <br /> COUNTY If JURISDICTION# <br /> /FACILITY# oZOO� n <br /> LOCATION QODE-OPTIONAL CENSUS TRAOT p - NAL <br /> 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 IWORMAtIOA ONLY. <br /> FORM A(6.95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 1 <br />