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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ;yP <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE m <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAIUTY NAME NAME OF OPERATOR <br /> ADDRESS NEARESTCpBe PARCEL#(OPTONAL) <br /> TREET <br /> r <br /> G5v <br /> 4 <br /> CITY NAME, STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> trE CA 1-753316 Zoa s11s- 3z&X_> <br /> ✓ BOX 0 CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' C11 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #ownerof USTis a public agency,complete the following:name of supervisor of dhoti ion,section or office which opeates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORO ✓IF INDRVATIAN #OF TANKS AT SITE E.R A. I.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER ORRTRUST LANDS �GJ•�� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L gy '— vlc > <br /> NIGHTS: NAME(LAST,FIRST) I IPHONE At WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME ,^./�� ^ CARE OF ADDRESS INFORMATION <br /> Levo D. <br /> M,AI;AG OR STREET ADDRESS ✓ bcrU ndta'e O INDIVIDUAL LOCAL-AGENCY0 STATE-AGENCY <br /> / v O CORPORATION 0 PARTNERSHIP UNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PON WITH AREA CODE <br /> v�✓� Oq `�533d ZCP,= -!,Z&0 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF NER CARE OF ADDRESS INFORMATION <br /> /L#4 i4" 5. �. <br /> MAILING OR STREET ADDRESS ✓ WOondiate DINDIVIDUAL LOCAL-AGENCY E3STATE-AGENCY <br /> /IN• 0, (jpx -sz—_ Q CORPORATION Q PARTNERSHIP [::3 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#AVITHI AREA CODE <br /> 3345 2 S>z4-3Za+o <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4174 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bor to indicate 0 1 SELF-INSURED 0 2 GUARANTEE o 3 INSURANCE 0 4 SURETYBOND E3 5 LETMROFCREDIT =6 EXEMPTIONO T STATE FUND <br /> 0 8 STATE FUND B CHIEF FINANCIAL OFFICER LETTER O #STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM D BB 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. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR`,,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> o Z- <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 7 <br /> 11 I I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-g5) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br />