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STATE OF CALIFORNIA •sy°�� <br /> STATE WATER RESOURCES CONTROL BOARD i r ,�.,' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORNI A T.,�yy� "'• c l <br /> Y//4l1 0. <br /> COMPLETE THIS FORM FOR EACH FACILRY/SRE <br /> • °•.,.,,y. . <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> C ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO <br /> CNE ITEM ❑ 2 INTERIM PERMITr lI A AMENDED PERMIT ❑ g TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME D` Mc FF.,� G NAMES OF_O'PERATOR <br /> ADCRESS # -� �'• 'ce- <br /> 33 V4 lI - ) Q I NEAREST CROSS STREET PARCEL A fOPrONAQ <br /> att Na•nE �'7'".)T <br /> / /C.� STATE ZIP CODE J SITE PHONE a WITH AREA CODE <br /> I/ Box CA 7 b <br /> TOMOICATE CORPORATION a INDIVIDUAL PARTNERSHIP U LOCAL.AGENCY Q COUNTY-AGENCY Q STATE.AGENCY <br /> DISTRICTS FEDERAL-AGENCYTYPE OF BUSINESS I GAS STATION ❑ 2 OISTR18UTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A L 0.a(opnma# <br /> 3 FARM a PROCESSOR 5 OTHER ❑ RESERVATION <br /> ❑ OR RESERTRUST ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NNAMEE(LAST.FIRST) <br /> NIGHTS: NAME(LAST,F R� �w <br /> PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PI IN E I WITH AREA Cl <br /> H c a R c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ` I CARE OF ADDRESS INFORMATION <br /> b 0 <br /> MAILING OR STREET ADDRESS ✓ M nuiOialA <br /> O INDIVIDUAL LOCAL-AGENCY [] STATE.AGENCY <br /> CITY NAME <br /> 1:1 CORPORATION Q PMRNEfl5III Q CWNTY-AGENCY C FEDERALAGENCY <br /> STATE ZIP CODE PHONE a WITH AREA COOS <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 13 A7)4P as a;ove. <br /> MAILING OR STREET ADDRESS ✓ lvznoraa <br /> INOIWWAL Q LOCAL.AGFWY C STATE-AGENCY <br /> CITY NAME Q CORPORATION 0 PARTNERSHIP = COUNTYAGENCY 0 FEDERALAGENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cal((916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 ALJ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eo:aiMkaN I SELF-INSURED 2 GUARANTEE ED T INSURANCE C3 A <br /> O 5 LETTER OF CREDIT 0$EXEMPTION SURETY BOND <br /> (] 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boEl or HIS checked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. IL❑ DL� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED b SIGNANREI APPLICANTS TITLE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �G <br /> COUNTY# <br /> JURISDICTION# <br /> q FA <br /> LOCATION OD •OPTIONaC CENSUSTRACTa • ZONAL SUPVISOR• `� <br /> 2 DI TRICTI CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION•-F RM B,UNLESS THIS IS A CHANGE OF S ,I+IRMATION ONLY. <br /> FORMA(Sg1) <br /> (, fCR5037A-5 <br /> I <br />