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STATE CFCALIFCRWA <br /> TE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR,., A �< <br /> COMPLETE THIS FORM FOR EACH F ITY!SFFE ^ �� <br /> MARK ONLY L_ I NEW PERMIT _I ] RENEWAL REKNIT CHANGE OF INFORMATION 7 PERMANE VTCLDSreB-Sgc <br /> CNE ITEM 1-1 2 INTERIM PERMIT 1 1 s AMENDED PERMIT 1 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYiSITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> n9AOR:ACILIN NAM / j NAME OF OPERATOR <br /> A/%07n �/✓ lit St7/Z/'�f <br /> ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAU <br /> CITY NAME " v� STATE <br /> CA ZIP CTJ SITE PHONE A WITH AREA CODE <br /> ✓ .'x <br /> ,n_,CORPORATION C INOIVIDUAL I_PARTNERSHIP t✓LOCAL-AGENCY C COUNTYAGENCY <br /> 70�NdCa7E C STATE AGENCY C FEDERAL AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS i� I GAS STATION 2 DISTRIaUTOR "' IF INDIAN ACF TANKS AT SITE E.P.A. L O.A f=W X) <br /> RESERVATICN <br /> G FARM C A P90CESSOR C 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> pur c f qc p�(Ic <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ mxob INONIDUAL C LOCAL-AGENCY C STATE-AGENCY <br /> C CCRPCRAnON PARTNERSHP C COUNTY4GENCY C FEDERAL-AGENCY <br /> CITY NAME I STATE I LP CODE I PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ m.4n9rAu <br /> C INDIVIDUAL a LOCAL-AGENCY C STATE- 'NCY <br /> IJ'CORPORATION C PARTNERSNP C COUNTY-AGENCY C FEDERALAGENCY <br /> CITY NAME I STATE LP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F47471-aaPjjjM 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓byevNkm lam__. I SELFINSURED = 2 GUARANTEE C 2 INSURANCE C A SURETY SONG <br /> C S IETTEROFCREDT C 8 ExEMPnON C 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTFICATK)NS AND BA.LNG: L 0 IL❑ IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL,CANTs NAME(PRINTED&SIGNATURE) APPLICANPS TITLE DATE MONTWOAYNEAR <br /> -27 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION x FACILITY a <br /> = STZ7lo 10 1 / <br /> LOCATION CODE -OPTIONAA� n CENSUS TRACT y,• N/L�� SUPVISOR-DISTRICT CODE -OPTIONAL <br /> M <br /> THIS FORMUST BE ACCOMPANIED BY AT LEAST(1)OR /SMORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(SAI) fCRLM17M3 <br />