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STATE OF CAL:FORMA a <br /> STATE WATER RESOURCES CONTROL BOARD "�•. <br /> / l UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORT A <br /> n <br /> COMPLETE THIS FORM FOR EACH F ;SITE <br /> MARK ONLY i_ I NEW PERMIT '1 3 RENEWAL PERMIT CHANGE OF INFCRMATICN J 7 PERMANENTLY ITS <br /> COTE ITEM I 1 2 INTERIM PERMIT h A AMENDED ?< I a .cMPORARY SITE CLOSURE <br /> I. FACILrrY151 ORMATION dt ADDRESS•(MUST BE COMP <br /> CdA�R:AC: NAME /NNAME .BATOR <br /> ACCREs / l'nt� NEA ESi R SS STREET � I PMICEL.OlITIONAU <br /> r NYC/ <br /> CITY.va•. I STA7r I ODS / I SITE PHONE,WITH AREA CCCE <br /> 6 Glo <br /> � 3c: <br /> TOMOCATE Ar*N Q RgNCUAI i�PWi `,IOCAL-AGENV Q COUNrY.AGEMY Q STATE-AGENCY Q FEDEAA 4cocY <br /> OBTRIC:s <br /> TYPE OF 3USINESS I GAS STATION = 2 DLSTR:eUTOA V IF ACIAN .OF TAN SITE E.T.A. E O.•Iomlmwl <br /> Q S FARM r-7a PROCESSOR G"1 S OTHER OR RESERVATION TRYST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OArS:NAME(LAST,FIRST PHONE.WITH AREA CODE DAYS:NAME(LAST,FIRST) <br /> NIGHTS:NAME( -__— YI'I1I/E,i`A :NAME(LAST,FIRSTI <br /> I. <br /> Eur c.p ARe&rmc <br /> PROPERTY OWNER INFORMATION• UST BE COMPLETED) <br /> CAREO� ESS O TICN744 <br /> G RA.V� ApO <br /> •lsNG CR STREET ADDRESS / �. W,oM Q INGMGUAL QI LOCAL.AGDCY Q i Ai.AGENCY <br /> glvv CORPORATION Q PAATNERSWP C UhTY.Ar ICY Q .cCE+AL.AGENCY <br /> CITY NAM STAIC ZIP CODE I PHONE a WITH AREA CODE <br /> v <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ACCRESS INFORMA- <br /> MAILING OR STREET ADDRESS ✓ aMamEHI, IQ XIVOULL Q LOCAI.AGENCY Q STATE-AGENCY <br /> Q COWRATION Q PARTWA" Q COUNTY-AGEPCY Q FMM44CACY <br /> CITYNAME I STATE I ZIP CODE PHOME,WITW AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGEFEE ACCOUNT NUMBER•Cali(916)323.9555 it ques5ons arise. <br /> TY(TK) HQ F4_74 -�I —)I 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> I SELFNiUREO L;T GUARANTEE Q 1 NSURANCE Q.stwii7dONO <br /> Q S LETTERCFCAEOT Q a CIEwnoN Q W oTIER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and blrwg will be sed to the tank owner unless box I or II is checked. <br /> CHECK ONE 3OX INDICATING WHICH A80VE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND SILLNO: L a IL CZ 14 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY WvCWLECGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME,PRNT-ED 6 SIGNATURE) APPLCARFS TITLE OATS MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> cranuHTve juals�. �Ac:Lm. <br /> F01 <br /> I/ 14/1CM <br /> LOCATION COOS .OPTIONAL CENSUS TRACT, -OPng("L SUPVISOR-DISTRICT CODE -rPTX)AAI. <br /> / *9 3 <br /> C8,v <br /> :71 <br /> HIS FCRM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SME INFORMATION ONLY. <br /> FORM A(5-al) FCRDMI" <br />