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_. I • • 061 - 1 <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLYI NEW PERMIT O 3 RENEWALPERMIT 5 CHANGE OF INFORMATION T PERMANENTLY C <br /> ONE ITEM `� 2 INTERIM PERMIT 4 AMENDED PERMIT -6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME �4/� , NAM OF OP RATOR <br /> S17 <br /> 14) <br /> ADDRESS NE ST CROSS FEET PARCEL I(UF IUNAU <br /> 4-4-b . Main S <br /> CITY NAME STACZIP <br /> A C DE SITE PHONE%WITH AREA CODE <br /> TOI/ BX INDIICAT61C'/y`'- I'CORPORATION 0 INDIVIDUAL /PARTNERSHIP [� LOCAL-AGENCY 50 COUMRAGENCY �STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> ✓ IF IN <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR DIAN #OF TANKS AT 517E E.P.A. I.D.%(optianap <br /> I= RESERVATION <br /> 3 FARM O 4 PROCESSOR O S OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /1 q -•' PHONE&WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE%WITHA ACODE NIGHTS: NAVE(LAST..FIRST) PHONE 4 WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD ESS 2 ✓ boxbNate INDIVIDUAL 0LOCAL-AGENCY O STATE-AGENCY <br /> 3 /1�`aYY S f -3 000RPORATION PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME G E STYE __ ZIP CODE PHONE%WITH AREA C-ODE <br /> 77/ <br /> III. TANK 44ER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER I CARE OF ADDRESS INFORMATION � <br /> MA ILING OR STREET ADDRESS ✓ box bintliI INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP O COUNTYAGENCV Q FEDERAL-AGENCY - <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to intlicate <br /> I SELF INSURED =2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> [ 5 LETTER OF CREgT 716 EXEMPTION L] 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 NOTIFICATIONS AND BILLING: I. II. IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OE MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED SIG AT RE) APPLIC IS TITLE DATEM TWOAYIYEAR <br /> LOCAL AGENC USE ONLY Z e C_ <br /> COUNTY# JURISDICTION ft FACILITY# , <br /> LOCATION CODE OPTIONAL SUS TRACT# OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL ^ O <br /> THIS FORM MUST BE ACCOMP I Y AT LEAST(1)OR MORE PERMI APPL CATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IN,FFORM Y. <br /> PORMA(1291) FILE THIS FO ITHT MPLEMENTINGTHEUNDERGROUNDSTORAGETANKREGULAjA�t�S �h.ty FOR0033AR6,�,// <br /> c0-4y4c" 6 i 3- i - � 1-r4,6 r'��` <br />