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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE 5 CHANGE OF INFORMATION ❑i T PERMANENTLY CLOSED MARK ONLY . E \ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS.(MUST BE COMPLETED) C NAMO OPERATOR/ DBAOF I FACILITY NAME ` ' q W L•'7 ` C" /4 STC SE PARCELX(OPPOMJQ N_ AD 55 �/ —/. I �J( c ST CA I ZI ODE ISITE PHONE WIAAFiF�000E CITY NAME / ,:R it 11 ..1 d((^/7 ✓ BOX ❑CORPOR TION WONIWAL ❑ PARTNERSHIP IyIJ Lam- SENCY Q COUNTY-AGENCY STATE-AGENCY ❑ FEDERAL AGENCY TO INDICATE 'Horner al USTa aPaB9c agenry.wm/Ielelha Neownq remedswervisaral Eivuion,seabawalfin wnxT°pmlee me U.ST yIF INDIAN pOF TANKS AT SITE cP.A. I.D.#(optional) TYPE OF BUSINESS ❑ I GAS STATON ❑ 2 DISTRIBUTOR ❑ RESERVATION ❑ 3 FARM ❑ X PROCESSOR E:21`5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAV ' NAME(I FxIR51) HONE p WITH AREA CODE DAYS: NAME(LA .FIRST) PHONE X WITH EA CQPE // l;�- -0 S ° J NIGHTS: ME(LAST, PHONE p WITH AREA CO E NIGHTS: NAM (LAS FIRST) PHONE a WITH AREA CODE x7 7 i{ I �6 -Z yr C;ll t T" II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) � - - ICARECF ADDRESS INFORMATION NAM rrtc f 1 L .%�^ N , . y �C:r ❑ INOIVICUAL LOCAUAGENLY STATE AGENCY MAILING O TR ET A y ESSCCRPCRATION Q PARTNERSHIP CCL'NTYAGENCY CDFEDERAL-AGENCY l�{CTS Q S T' CO PHONE X WITH AREA CODE CITY NAME III. TANK OWNER IN ORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION J NAMEgg.4 VNER Q G I� f% E ✓ E°x to°rlirale Q WOMDUAL LOCAL AGENCY OSTATE-AGENCY MAILING TRE gp0RE55 ^7 U `` J( 0 CORPORATION a PARTNERSHIP ❑COUNTY AGENCFEDERAL-AGENCY �J S" A I ZIP ODE ^�� PHON W — AREA CODa 4 CITY NAM �� L Oj'S S' IV. BOARD OF ALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO F474-]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ooxrovNirate-= , SR-F'INSURED O 2 GUARANTEE Q 3 INSURANCE I0 9 SURETVBONO O S IETIER OFCREOIT =6 EXEMPTION ❑T STATEFUNO Q 9STATE FUND&CHIEF FINANCIAL OFFICER LETTER I=9 STATE FUND&CERTIFICATE OF DEPOSIT QID LOCAL GOVT.MECHANISM 990THEP VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD Be USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III'❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRE07 TANK OWNER'S NAME(PRINTED 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY q COUNTY X JURISDICTION Al FACILITY X l SUPVISOR-DISTRICT CODE -O TI NA LOCATION CODE .OPTIONAL CENSUSTRACT# -OPTIONAL S THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)