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• c1 / <br /> STATE OF • � � �r a� , "�"•"^<�,, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> G UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM �r i <br /> ra y` \• <br /> COMPLETE THIS FORM FOR EA FACILITYISITE a o <br /> MARK ONLY ❑ I NEW PERMIT 7 RENEWAL PERMIT o• <br /> ONE ITEM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBAD FA LITV NpM� Ca <br /> r�J I NAME OF OPERATOR �7 <br /> ADORE <br /> CITY NAM OZ NEAR TCR STREET PARCEUIOPTgNAU <br /> STATE ZIP CODES17E PHONE#WITH AgEA CODE <br /> I/ BOX CA <br /> TOINOICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> DISTRICTS Q COUNTY AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN p OF TANK SITE E.P.A, L p,;(Q.... q <br /> ❑ ] FARM ❑ a PRCCESSOR ❑ 5 OTHER O RRgU57VLANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST.FIRSn EMERGENCY CONTACT PERSON (SECONDARY)•Optional <br /> PHONEa WITH AgEA CODE [NIGHTS: <br /> ME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,Flq$1) <br /> PHONE A WITH AREA CODE <br /> AME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED H <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ EC.b Mkw, Q INDIVIDUAL <br /> CITY NAME Q CORPoPATION Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q PARTNERSHP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ lba biMkap Q INDIVIDUAL Q <br /> �] LOCAAGXCYCIN NAME Q STATE AGENCY <br /> ppgiNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY <br /> IV. STATE ZIP CODE PHONES WITH AREA CODE <br /> TY(TK) HO 44 - <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•--11,­N23-9455 916)3if questions arise. <br /> TY <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ lba biMlCaM Q <br /> ISE -if SU ii Q 2 GUARANTEE <br /> Q 5 LETTEROFCREDIT Q a EXEMPTION Q] INSURANCE Q a SURETY BOND <br /> Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent tG the tank owner unless box I or II is checked. - <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLCANTS NAME(PR WTED 8 SIGNATURE) <br /> APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �` <br /> C�OO��UNNTyTYY�# /'/L;T�/T�it//.{j�, JURISDICTION# <br /> `� T P100/�R•-'30FACILITY# <br /> [LOCATIONOPTIONAL CENSUS TRACTJ - nONA1 ISUPVISOR.OISTRICT CODE <br /> 2-3. �0 2 apnoNaL <br /> THIS FORM MUST BE ACCOMANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION FORM B UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. ' <br /> FORMA(591) <br /> )l FOWJ=A4 <br />