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STATE OFCAUFORNIA ! Ei <br /> �TE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR)' A ;• ,; i1 !: <br /> COMPLETE THIS FORM FOR EACH -CILITYISITE <br /> 1 NEW PERMIT O RENEWAL PERMIT 5 CHANGE OF INFORMATION V T PERMANENTL <br /> MARK ONLY L� _ <br /> CNE ITEM 1-1 2 INTERIM PERMIT a AMENDED PERMIT El e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATO <br /> CBA OR FACIL17Y NAME <br /> 5I , J"�,I l(S Zr65 MAN li�.G I: <br /> NEARED CROSS STREET f I ?ANCEL CPfgNAU <br /> aDOAESS /��A / / /� /t / 'LL <br /> WITH AREA CODE <br /> CITY NA`.IE STATE ZIP CODE ' SITE PHONE A <br /> ✓ 9CX �— PARTNERSWP =1 LOCAL-AGENCY Q COUNTYAGENCY CI STATEAGENCY � FEDERAL AGENCY <br /> TO,NDCATE 'J1 LCPPoPATION INCIVgUAI _ OGTRgTS <br /> TYPE OF 36SINESS I GAS STATION '—I 2 OISTR3UTOR L <br /> 11 IF INDIAN a CF TANKS AT SITE E.P.A. L D.A(aptiawl <br /> � RESERVATION <br /> O FARM A PROC'c SSCR C 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS:NAME(LAST.FIRST) PHONE P'NITH AREA CODE DAYS: NAME(LAST,FIRST( <br /> 0 <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRSTI <br /> P CAV Rc c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING CR STREET ADDRESS I ✓ WXnIt1 m Q INGNIOUM = LOCAL-AGENCY C STATE-AGENCY <br /> Q CORPORATION = PARTNERSWP Q CWNrY#GENCY FVERAL-AGiNCY <br /> CITY NAME I STATE i ZIP CODE I PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF A00FIESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ MII; XaA Q INOIVOUAL G LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEOEPAL.AGENCY <br /> CITY NAME I STATE I ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ [4 72 I- 0 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED <br /> ✓tIm LYIAh L".: 1 SELFINSUREO IJ 2 GUARANTEE U 2 INSURANCE O A SURETY FOND <br /> =S LETTERCFCREOR S EXEMPTION [:3 99 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 MOTIFICATK)NS AND BILLING: L= IL= IN. <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 A SIGNATURE) APPLICANTS TITLE DATE MONTWAYlYFAA <br /> 2- <br /> LOCAL <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION A FACILITY a <br /> MI F= ST,4,vrn- o `21112 = <br /> LOCATION CODE -OP7fONAl (CENSUST�TA •OPISOR <br /> i^NAL SUPV -DISTpZCODE -OPTIONAL <br /> u1 Y �� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S-91) ( FORMA-5 <br />