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• STATE OF CALIFORNIA <br /> /} STATE WATER RESOURCES CONTROL 80ARO • <br /> k,_ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA �,.1 aFORM FOR EA FACILITY/SITE ' <br /> MARK ONLY I_I 1 NEW PERMIT 3 RENEWAL PERMIT ly 5 CHANGE OF INFORMATION <br /> 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM <br /> 2 INTERIM PERMIT � A AMENDED PERMIT F-1 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OA,FAOILITY NAME NAMEOFOPERATOR <br /> ADORE W^L/)'V�LAJ Tn 1) <br /> ��nU NEARn TCRSSTREET PMCEU(O710NAL) <br /> CI NAM <br /> STATE i ZIP CODE I SITE PHONE A WITH AREA CODE <br /> ✓ EOx <br /> TO INDICATE L1 CORPORATION Q INDIVIDUAL J PARTNERSHIP Q LOCAL AGENCY Q COUNTY AGENCY <br /> DISTRICTS O STATE AGENCY a FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKs AT SITE E.P.,:,. I.D.A(nplimap <br /> O D FAI3M O d PROCESSOR 5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME;LAST.FIRST) PHONE i WITH AREA CODE <br /> T,,GmTs7 <br /> =TFIRST====:: <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE ) <br /> PH f I C <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ Om bitbbiq Q INDIVIDUAL <br /> E�PHONE <br /> acENcr O STATE AGENCY <br /> CITY NAME Q CORFORATION C ppgTNERSWP TY-AGENCY �1 FEDERAUAGENCY <br /> STATE ZIP COCE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STgEET ApORESS <br /> ✓ �i b WKua 1 INDIVIDUAL <br /> Q PR R _C AnON O-I LOCAL AGENCY I� STATE AGENCY <br /> CITV NAME CI PARTNERSHIP Q COUMYAGENCY l� fEDEMLdGENCY <br /> STATE I ZIP 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 4747,- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Porbin W. r I SELF INSURED L= 2 GUARAMEe (] O INSURANCE <br /> O 5 LETTEROFCREO(T =g E%EMFDONQ 99 OTHER A SURETY BOND <br /> Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS - <br /> CHECKONE BOx INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> L� IL� Ill.�j <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) <br /> APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION x <br /> Woo k 30 <br /> FACILITYq <br /> LOCATION COCE %PTIONAL IAL (CENSUS TRAC�lT♦ .OQ7l0- � q <br /> /� J C6J ISUPVISZOR-DISTRICT CODE -OP7/ONA1 <br /> THIS FORM MUST BE ACCOMPANIED 8Y AT LEAST(1)OR MORE PERMIT APPLICATION F RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(SAI) <br /> ^ FORpSUA-5 <br /> �Ih i <br />