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*�ya�pces c <br /> STATE OF CALIFORNIA o" <br /> r <br /> e' 4 <br /> STATE WATER RESOURCES CONTROL BOARD 3- ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> • CSC�f URNr <br /> COMPLETE THIS FORM FOR EACH FACILITYISITIE <br /> MARK ONLY F_� 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANENTLY <br /> ONE ITEM E:1 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FAIDDIRESS <br /> OR FACILITY NAME } /` NAME OF OPERATOR //r�� �1 <br /> N ARFST CROSS STREETPARCEL 4(OPTIONAL)`SNAME STATE ZIP CODE SITE <br /> PHONE#WITH AREA CODE <br /> CA X533 <br /> BOXINDIVIDUALINDIVIDUAL 0 PARTNERSHIP ll LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TO INDKATE DISTRICTS <br /> TYPE OF BUSINESS ��GAS STATION 2 DISTRIBUTOR I/ ":INDIAN #OF TANKS A7 SITE E.P.A. D.#(optional) <br /> RESERVATION <br /> C_j 3 FARM Q 4 PROCESSOR = 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: NAM7E(LAST,FIRST) g�'r- <br /> o VA Val (C"D z x717 v; - <br /> NIGHTS: NAME(LAST.FI ) PH Eta ITH AREA CODE NIGHTS: NAME(LAST, RST) <br /> it. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME TC.IZ <br /> FORMATION <br /> ir <br /> MAILING OR STREET DRESS <br /> ® or <br /> INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 6 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME <br /> STATDE PHONE#WITH AREA CODE <br /> G �JC� Z _ 8-3 5 Z7517 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �S <br /> MAILING OR STREET AD KESS ✓ box to indicate 0 INDIVIDUAL l7 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP [] COUNTY-AGENCY i� FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONF#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)323-9555 if questions arise. <br /> TY(TK) HQ F41A]-.d Z ih7 Lk 1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindicate I SELF-INSURED 2 GUARANTEE � a JNSURANCF 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 0 99 OTHER <br /> VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notiiicafson and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONS BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> aC� �— <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, 5 <br /> FORM A(5-91) <br /> A--/ <br />