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STATE OF CAUFOFNA cti <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br />COMPLETE THIS FORM FOR EACH FACILITYISiTE <br />1 NEW PERMIT ❑ 3 RENEWAL PERMIT (K 5 CHANGE OF INFORMATION ❑ i PERMANENTLY CLOSED SITE <br />MARK ONLY � s AMENDED PERMIT `❑ 6 TEMPORARY SITE CLOSURE <br />ONE ITEM ❑ 2 INTERIM PERMIT <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />of OPERATOR DBA OR FACILITY NAME w` _ (? <br />0ILLe7 "IFNapt 41446171 <br />CROSS STREET PARCELW(OPTbNAU <br />ADDRESS iG V� $EN NOL- D2 <br />W p CODE <br />G r� ,. , p SITE PHONE s WLr�P.H AREA CODE <br />( <br />CITY NAME ST0 ,. . L _-'I-00 ST CA ZIP0 9-'"•`-r I W I — <br />LOCA4AGENCY ®COUNTY AGENCY (� STATE -AGENCY � RE)M AGENCY <br />TOINa TE p CORPORATION [� INDIVIDUAL 0 PARTNERSNIP r �FGCTS <br />✓ If WDWN x Of TANKS AT SITE E.P.A. L 0. a /aPt�%1 <br />TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR RESERVATION /1 C 1- � 2905115 <br />C33 FARM Q 4 PROCESSOR C) 5 OTHER OR TRUST LANDS I <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) •optional <br />DAYSa(LAST. PHONE a NTTH A�R/EA C,OrDE DAYS: NAWM�E (,LAST. FIRST) �o jf„ 4-77 �,'6”'FK��®rel(AST. FIIi°i' F IL _ <br />NIGH) a7Q ��1�('7 L� <br />II. PROPERTY OWNER INFORMATION - MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br />NAMEfORSTREET <br />��s,.a •�(�'()G�j Cit? <br />✓ bolt indicate Q INDIVIDUAL (� LOCALAGENCY STATE•AGENCY <br />MAILINADDD�RREESS �®O e P��(7 P ® �1NTY-AGENCY a FEDERAL -AGENCY <br />gL�STATE ZIP CCODtE Gly PHONE s Wn'H AREA COOECITY � Y"�� ry _t ('t• JV ':j <br />Ill. TANK OWNER INFORMATION - (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br />NAME OF OWNER / -fee <br />C:� <br />iT <br />box 0 CD N VIDUAL I_] LOCALAGENCY a STATE-AGENCYMAILING OR STREET ADDRESS D®` � ON PORATION Q P�WRSRP COUNTY-AGENCYY (] FEDERAL AGENCY <br />��®��./ X G -E ORAZIP COt Q, g PHONEI u WITH AREA CODE <br />CITY NAME 5�s' VIV 9�'`o.;1 ✓fig® �K� t� <br />IV. BOARD OF E/QVUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4- ®`' I q t •3 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED d SURETY SONO <br />2 GUARANTEE a 3 vmRANCE O <br />✓ box It k dicaa W5 LEITER OF CREDIT 0 6 D(EMPnON 0 so 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: <br />L ❑ IL ❑ IN <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />�Z <br />/�PLx:ANTS TITLE GATE MONTH/OAY/YEAR <br />APPLICANTS NAME (PRWTED 8 SIGNATURE) ��L - �t7� �� � p <br />rZ <br />t�6,tJI✓Ti£ 1�1A.w1E.tj <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />JURISDICTION # FACILITY # _ <br />iF <br />PVISOR - DISTRICT CODE - OPTIONAL <br />LOCATION CODE - OPTIONAL CENSUS TRACT s -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 FOROM A 5 <br />FORM A (5.91) <br />