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EgOUACfS <br /> STATE OF CALIFORNIA h:r , cO <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA . <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE 'o <br /> MARK ONLY 71 NEW PERMIT 0 3 RENEWAL PERMIT Er 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOS ITE <br /> ONE ITEM a 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 7 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D OR FACILITY NAME (®�jJ� NAME OF OPERATOR <br /> V P�-IIS- �� ffiavtv�-c�C 'N S9 _ P,49.V. A5 I CJI <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME ( STATE? �� <br /> ZIP u, SITE PHONE#WITH AREA CODE <br /> � 2 <br /> ✓BOX a CORPORATION INDIVIDUAL 0 PARTNERSHIP ED LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> H owner of UST is a public age X11(-complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> /�� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:�AME(LAST,M���RS�� PHONR�1� ©C� #WITH AREA i �'CODE�� DAYS: NAME r�S T)4s 1 PHONE#WITH A CODE <br /> aYj-4 41k <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) G1`r «PHONE i{#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> N CApgA ADDRESS INFORMATION` <br /> MAILING OR STREET ADDRESS ✓ box to indicate 3:],4MVIDUAL lj LOCAL-AGENCY (]STATE-AGENCY <br /> I 0_111Z- =CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME SjAj®_ Z�r P #WITH AREA CODE14 k <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA�f Q OF OWNER Cfkj3E OF AD RESS INFORMATION <br /> d � r d, t <br /> M (LING ORST EE ADDRESS ✓ box to indicate (DUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 2Q// CORPORATION (] PARTNERSHIP OCOUNTY <br /> -AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMESTt1TE ZIPWOD PHONE#WITH COD41 E X <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/(-Call(916))322-9669 if questions!aririsoe. <br /> TY(TK) HQ 4 4- - C1 ?_ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 7 STATE FUND <br /> (] 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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.El III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SI ATURE) TANK OWNER'S TITLE DATEMON 1DAYNEAR <br /> t�warA- zta <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m Aa <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> (t 12(,[ 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFbRMAbON ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM VWHE LOCAL AGENCY IMPLEMENTING THE UNDERGROU JWRAGE TANK REGULATIONS <br />