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4RECEIV <br /> L STATE OF CALIFORNIA � <br /> STATE WATER RESOURCES CONTROL BOARD FEB ' '� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATIGN <br /> ��IFOPN`� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE PERMIT/SERM of <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR i <br /> 1 <br /> �`�( _ <br /> ADDRESS NEAREST CRO//SS STREET PARCEL#(OPTIONAL) <br /> Ye'tI`c G6✓1 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c✓: � CA C15304 <br /> ✓ BOX <br /> TO INDICATE CORPORATION >a,INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS'0�q 1 GAS STATION 2 DISTRIBUTOR0 R SV IF ER INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR 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) '1 i ^Oy�P_t <br /> �/ O 0� <br /> PHONE A WITH AREA MID <br /> NIG - NAME AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> f-83,6— (_)7-/ d PHONE#WITH AREA CODF: <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> t< f R_q� %'k <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> d"D CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER L CARE OF ADDRESS INFORMATION <br /> it <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 4(Q C44140-"— <br /> (]CORPORATION = PARTNERSHIP E::]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME �� STA ZIP CODE C153'ry PHONE#WITH AREA C�� <br /> h [.v 7 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [414]do —t <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED Q 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 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.V<1 II.F-1 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> Af0c <br /> AME PRINTED&SIGNATURE) APPLICANT TITLE DATE MONTWDAYNEAR <br /> v ` 0R193,G USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 0 <br /> I� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORM A(5-91) FOR0033A-5 <br />