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/ • STATE OF CALIFORNIA • l L� 'O �_ <br /> STATE WATER RESOURCES CONTROL 80ARD <br /> L�S✓ I/ E/ l 1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM VvV-' <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> 1 NEW PERMIT C C/ <br /> EMA7AKC�NMY LJ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT d AMENDED PERMIT <br /> 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) 3 <br /> 00A 0f>,F'6I AM� <br /> IV,U /,1Jt NAME OF CPE RATOR <br /> AOC"nE / <br /> NEARTCR SSTREET i PARCEL I(OPIONAL) <br /> CITY NAM VV w w <br /> STATE I ZIP CODE SITE PHONE y WITH AREA CODE <br /> ✓ So <br /> CA <br /> TOINDCATE Q CORPORATION INDIVIDUAL PARTNERSHIP LOCALAGENCY <br /> I� DISTRICTS COUNTY AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS u I GAS STATION a 2 DISTRIBUTOR ✓ IF INDIAN y OF TAN SITE E.P.A. 1.D.y(oplimalJ <br /> 3 FARM Q a PRDCESSOA 0 5 OTHER OR <br /> RTRUSTVATIO <br /> LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME;LAST.FIRST) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> PHONE y WITH AREA CODE DAYS: NAME(LAST,fIR 11 <br /> NIGHTS: NAME(LAST,FIRST) PHONE y WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PH c y I c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> CAAE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ Ma binaicaU INDIVIDUAL = LOCAL-AGENCY STATE AGENCY <br /> CITY NAME CORPORATION LJ PARTNERSHIP '= COUNTWIGENCY FEDERAL AGENCY <br /> STATE 121P COLE PHONE y WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADOaESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ WX 4mIcau I� INDIVIOUAL <br /> CITY NAME ( U LOCAL-AGENCY Q STATE-AGENCY <br /> ]CORPORATION � COUNTY AGENCY Q FEDERAL AGENCY <br /> COE PHONE y WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMSTATE I ZIP CBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 'Im blMKab i_I 1 SELF-INSURED 2 GUMAME"c <br /> 5(ETTEROFCREOfT =8 EXEMPTION ❑ 3 INSURANCE O A SURETY BOND <br /> Q 99 OTHER <br /> EEVI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> E 30X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.= IL= IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANT'$TITLE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY amvitJURISOICTION# <br /> WOODR <br /> 177 FACILITY N <br /> LOCATION CCCE OPTIONAL CENSUS TRACT y-30 <br /> TIONAL �� VII <br /> II 23. d ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS ECRM MUST BE ACCOMPANIED 8Y AT LEAST(1)OR MORE PERMIT APPLICATION 7'FORM B, UNLESS THIS IS A CHANGE OF SITE INFOflMATION ONLY. <br /> FOR <br /> (591) r <br /> I A FORO=AS <br />