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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 1 NEW PERMIT ❑ S RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> MARK ONLY ❑ y AMPERMIT 6 TEMPORARY SITE CLOSURE <br /> ONE ITEM ❑ 2 INTERIM PERMIT <br /> I. FACILITYISITE INFORMATION&ADDRESS.(MUST BE COMPNAMLETEpEOF wEFuroR <br /> DBA OR FACILITY NAME PARCFl9(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRESS 'SO <br /> TE PHONE 9 WITH AREA CODE <br /> STATE LP CODE — <br /> CITY NAME CA Z <br /> PARTNERSHIP O LOCAL-AGENCY (]COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> ✓BOR CORPORATION (]INDIVIDUALO DISTRICTS <br /> TO INDICATE <br /> •9ovmarof UST65PdbkagNwY.lwa'P'Na NAlolbwng Nanadaupemsord Crvuwn,saownwoxwa xfid�°PaWesthe US ✓IF INDIAN tOF�KS ATSITE EP.A7Lo , <br /> DISTRIBUTOR RESE ON <br /> TYPE OF BUSINESS 1Q 1 GASSTATION ❑ Q PROCESSOR 5 OTHER aOR TRUST LANDS <br /> ❑ 3 FARM ❑ O <br /> EMERGENCY CO77MRIEE <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,RR511 PHONE A WITH AREA CODE <br /> DAYS: HINAME(LAST.EFIRSL DE ' T L '77 ODE NIGHTS: NAME(LA T,RBST)NIGHT4 Z q <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME , <br /> (� PQ ✓ boaw iwcala 10 NgyIWAL ED LOCAL-AGENCY O STATE-AGENCY <br /> MAILING OR STREET ADDRESSCpepORATION O PAIRNER519P O COUNTY-AGENCY O FEDERAL-AGENCY <br /> STATE ZIP�CLODE PHONE a MOTH AREA CODE <br /> CITY NAME aX 9-1�7�7 197.5—�7fe To' 6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ��tLA ✓ boaw iw+ale �NOMOl1A LOCAL AGENCY O STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> O CORPORATION O PARTNEBSIi O COUNTYAGBICY FEDERAL-AGENCY <br /> PHONE f WITH AREA CODE <br /> STATE ZIP CODE �L /�q <br /> CITY NAME �A 5L,J/ L" `�39•L 61 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 F4- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boRwivlkala SELF.INSURED ED 2 GUARANTEE 0 31NSURANCE I]A SURETYBOND 0 5 LETTEROFCREDR Q& E%EMP" 0 7 STATE FUND <br /> 6 STATE RIND 6 CHIEF RNANCIA OFFICERLETTER O 9 STATE RIND&CERTIFICATE OF DEPOSIT 0 16 LOCA GOVT.MECHANISM O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tardy 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.❑ l T III.IVI <br /> THIS FORM HAS BEEN OMPLETED U DER P TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEMp CORRECT �1 <br /> TANK OWNER'S NAME(PRIN !!yR' TANKOWNER'STITLE �F .,�.+E-+� <br /> c / )R <br /> LOCAL AGENCY E ONLY <br /> COUNTY k JURISDICTION N FACILITY a 7 <br /> m p t <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> I e 99 <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 /> FORMA(6.95) OWNER MUST FILE THIS FORM Is HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNi f RAGE TANK REGULATIONS <br />