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w sour es <br /> rL"- <br /> e <br /> %C <br /> STATE Of CALIFORNIA EIVE <br /> STATE WATER RESOURCES CONTROL BOARD MAY 13 1993 3 . <br /> ////�/j}►�� UNDERGROUND STORAGE TANK PERMIT APPLI���1 � <br /> / <br /> HEAL <br /> i <br /> PERM IT1§ERV10j§ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 1y 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT yup 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA ORF CILITY NAME F O ERATO <br /> Ip <br /> 'Coe�' (;(2 S r 4 <br /> ADDRES N EST CROSS ST T PARCEL (OPTIONAL) <br /> 9 > <br /> CITY NAVE / STATE ZIP CODE SITE PHONE#WITH AREA CO <br /> L-atk rp Ca p _ 1 <br /> ✓ Box <br /> TO INDICATE CO RATION1DIVIDUAL PARTNERSHIP OLOCAL-AGENCY OCOUNTY-AGENCY OSTATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(ptional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N ME(LA)FIRST)^n PHONE#WITH AREA CODE DAYS: NAM ST,• IST) tw / n���PNQOo LAR60!F� <br /> NAME( T,FIRST`)J'1G PHO TH AREA CODE NIG T : NAME(LAST,/,yIFIUR\ST)i'Y'/•1nC O <br /> �;%e cis bove <br /> II PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> ME CAREOF ADDREPP INFO MATION — <br /> Corti, Unv ka <br /> MAILI OR STREET DDRESS ✓ box to indicate INDIVIDUAL LO L-AGEN 0 STATE-AGENCY <br /> OK O CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY N ME STATE ZIP CODE PHONE#WITH AREA CODE <br /> FT 61V_Q C D 42 - C /� -O - 3/ 9- <br /> I )TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> E QF OWNERn CARE OF ADDRE S INFOR I N <br /> a <br /> 1'bA h E L. __So <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL GENCY =STATE-AGENCY <br /> Same, SL =CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA COX <br /> C'0 -- I qoaoa3 0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0101 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> V EGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> C CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= it.= III.`tel IXi <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT I <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE / DATE MONTH/DAYNEAR <br /> • t.7 rteo iiom x• T-� V. /T S S r'S <br /> LOCAL AGENC YUSE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Q�CO S SS <br /> IzF3 � 5 b <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL \I`93 rJ�Ji <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE I T N ONLY. <br /> FORM A(5-91) G FOR0033A-5 <br />