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4 -C l <br /> l^ <br /> STATE OF CALIFORNIA u <br /> STATE WATER RESOURCES CONTROL BOARD .. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA <br /> COMPLETE THIS FORM FOR EAC"ILITYISME <br /> I NEW PERMIT Q 3 RENEWAL PERMIT It 5 CHANGE OF INFORMATION T PERMANENTLY CL.OSrFD, jlT'E <br /> MARK ONLY it j <br /> ONE ITE41 2 INT <br /> PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE - <br /> I. FACILITYISITE INFORMATION &ADDRESS-(MUST BE COMPLFED) <br /> NAME OF OPERATOR <br /> � <br /> CBA OR FACSLJIY NAME � f ����� ter' ��t �–•'� <br /> ©u i r..i v. C f- '1f�U t ✓ 1 f f PARCQ,(aPn«aw <br /> NEAREST cRass sTRe= <br /> ADDRESS ' <br /> -7 - = f.�ur1 ry (,iJo I..r . <br /> STATE DP CODE SITE PHONE t WITH AREA CODE <br /> CSTY NAME CA <br /> Uri <br /> ✓ BOX CDIaPORATICN Q NDMDUAL Q PAMEiSHIP L0C � OM -AGDCY- 9� STATE4MCY' FMERAL.AGENC`�' <br /> a9CT5 <br /> i O INDICATE <br /> Y a„ner of UST a a Pl�hfic a9e^�Y.m"oMla ^¢ �"°d swery su d dr+sion.saR on at otfica rsodl opelata�°UST ✓IF INDLAN NOF TANKS AT SITE E P.A. L D.N(00mm0 <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR RESERVATION r+ <br /> 3 FARM Q A PROCESSOR S OTHER OR RUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PH NE I1 WITH AREA GDOE GAYS: NAME(LAST.RRST7 <br /> PHONE N WLTH AREA CODE <br /> E ­ <br /> 1. <br /> E(YLAST.FIRST) • l�� INIGHTS NAMAE(LAST.FIRST) PHONE s WITH AREA CODE <br /> S i 'r1R5 i� PHONE 4 WITH AREA CODE <br /> r <br /> PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> ; {{� 5` <br /> NAME <br /> •5 �� . ;'� <br /> 7 r�; j'r �" J ' I_' k ✓ drat a m nta SiOTADUAL L LOP AL AGENCY STATE-AGENCY <br /> F IAIUNa ORS BEET ADDRESS CORPORA <br /> i aARTNERSIfIP CGUNTY-AGENCY © FED@gAL-AGENCY <br /> _ TION C <br /> ', '�• "11 / STATE ` z!P COOS _ I PHONE WITH AREA CODE- v <br /> CITY NAME 17r..,w !(�1 I I `��. , 0✓-7~a�r.> <br /> 7;5, z <br /> M. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARA <br /> E(}F ADDRESS INFOR AiION <br /> N ME OF 9SVNER <br /> r'baloidC21 C ;NDMMAL C LOCAL•AUdA-1 �--d'-J STATE-AGENCY <br /> .MAILING OR STREE i ADDRESS( I <br /> G ` i�CORPORADON �� PAMNERSHIP COUNTY-AGENCY �! r-ERAL•AGMCY <br /> I /PHONE#WITH AREA CODE <br /> CITY NAME 'k I f L� G r'�7~ Z7 G <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cail(916)322-9669 ifi questions arise. <br /> TY(TK) Iia F4747- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED r STATE FUND <br /> ✓to=IoirlC Cali = 1 SuF•iNSUFIED Q 2(aIJAFlA?IiSE C 3 INSURANCE Q<SURETYBONO 5 LETTEROFCRH]fT 6 <br /> Q d STATE R3ND a CHIEF fINAlJ�ChL OFFICER LEITER C 9 STATE FUN]&LcaTIROATE OF LEPOSIT = 10 LOCAL GOVT.MECHANISM 0 99 01 ER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and bitting witl be sent to the tank owner unless box I or II is checked- <br /> CHECK ONE 80X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL.NOTIRCATIONS AND 91LlING. <br /> L= 1I.G III.Qj <br /> ir!!5 FOAM NAS 3E.=N COMPl�ED UNDER PENALTY Of PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S T74UEAND CORRECT <br /> 11 M4TWVrDf+A <br /> YN <br /> EAR <br /> 7--- <br /> TANKDWNFiSTITLE DATE <br /> TANK WNERSfNAME(PRINTEO&SIGNATURE 'E <br /> LOCAL AGENCY OSE ONLY �, [� 41✓ <br /> COUNTY x <br /> ,JURISDICTION# FACSLITY <br /> I� I <br /> LOCATION CODE •OPTIONAL (CENSUS TRACT• •OPTIONAL <br /> `SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST SE ACCOMPANIED BY AT T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILL=THIS FORMW i HE LOCAL AGENCY IMPLEMENTING THE UNDEAGRO''WORAGE TANK REGULATIONS <br /> FORM A 16-351 <br />