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` C , STATE OF CAUFOWLA STATE WATER RESOURCES CONTROL BOARD •"� „p UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA C�li.OnY,- tr COMPLETE THIS FORM FOR EACH FACILITYISITE ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ fi CHANGE OF INFORMATION 7 PERMANENTLY CLO O MARK ONLY a TEMPORARY SITE CLOSURE ONE REM ❑ 2 INTERIM PERMIT [D 6 AMENDED PERMIT ❑ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERATOR DBAOR FACILITY NAME '1 14Kp' Imr PARCEIa(OPrKINAy NEA TCROSS STREET ADDRESS r STATE ZIP DE SITEPHONE>I WITH AR------ 3 3 'T vrT CITY AMEN CA / BOX\X LOCAL-AGENCY C:]COUNTY-AGENCY O STATE-AGENCY' ED FEDEML-AGENCY' , TO I/ Box 0 CORPORATION INDNIDUAL PARTNERSHIP DSTNCTS' at"the •N owner d UST le a pubic agency,mrnPI the todowlng:name of Superveor of dIv section or oNim whk�e IF INDIAN 8 OF TANKS AT SITE E.P.A. 1.D.If(oWi nal) TYPE OFBUSINESS ❑ 1 GASSTATION ❑ 2 DISTRIBUTOR RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•*on0' DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PH ONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PROPE INFORMATION• MUST BE COMPLETED a CARE OF ADDRESS INFORMATION NAME r HJ ✓ ombindIC& INDIVIDUAL = LOCAL-AGENCY E2 STATE-AGENCY MAIL G, RSTREET DREE CORPORATION O PARTNERSHIP = COUKrY.AGENCY 0 FEDERAL-AGENCY L/C/^ Oj I fJi(/ YPHONE a WITH AREA CODE eTc�h ZIP°5 a CI NAME �0, C� III. TANK 0 CARE OF ADDRESS INFORMATION NAME OF OWNER ✓boa b W'CO 0 INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY MAILING OR STREET ADDRESS Q CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY STATE ZIP CODE PHONE a WITH AREA CODE CITY NAME IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ,SURETY BOND ( 1 SELFINSURED =12 GUARANTEE O 7 INSURANCE D ✓ bwtbindkate0 SP OTHER =5 LETTER OF CREDIT Q fi EXEMPTION VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: ❑ a� nl.� THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED A SIGNED) r7=:;::: DATE MONTWDAVNEAR 17 LOCAL AGENCY USE ONLY '— JURISDICTION# FACILITY# amCOUNTY# F= F=1= LOCATION CODE -OPTIONAL CENSUS TRr]CT -OPRRNA� SUPVISOR-©� CODE OPTIONAL - THIS FORM MUST BE ACCOMPANIED BY ATLEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IIFORYIIATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND RAGE TANK REGULATIONS FORoroHa FORM A(393)