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w 0 4�`pCr9 <br /> •� co <br /> STATE OF CALIFORNIA <br /> 9 <br /> p � 7 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA .q � `4° <br /> _ C•llnUM p'' <br /> COMPLETE THIS FORM FOR EACH rTYISITE <br /> MARK ONLY t NEW PERMIT F7 G RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER Y CLOS ITE <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 a AMENDED PERMIT 8 TEMPORARY SITE CLOSUREZX <br /> __j- <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF O RATOR <br /> PARCEL It(OPTIONAL) <br /> ADDRESS NEAREST CA STREET <br /> r7 y] <br /> CITY NAME f STA7CJEp ZIP CODE E PHOE WEA C� / <br /> 4f C' flJi�r�, L <br /> ✓ SOXCORPORATION INDIVIDUAL PARTNERSHIP © LOCAL-AGENCY Q COUNTY-AGENCY OSTATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION �--��tt 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.0(optional) <br /> LJ 0 RESERVATION <br /> = 3 FARM a PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: AME(LAST,FIR PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NM1GHTS: NAM (L'T,FIRST) PHONE»WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> H x <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> ',)} /-- CARE OF AD SSfINFORMATY/i ] <br /> NAME �.� tl e G <br /> MAILING OR STREET ACD RE S I ✓ box n i kale 0 INDIVIDUAL LOCAL-AGENCY _ STATE-AGENCY <br /> �i 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> 3 <br /> ST ZIP CODE PH NE e WITYArV OOE 7� <br /> 15� 7/_ CJ LLLLLL [r�� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box Io mftze INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE j ZIP CODE PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_74 - G) 5 I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE ME (S) USED <br /> tSELF-INSURED 2 GUARANTEE ]INSURANCE d SURETY 80NO <br /> box binocate 5 LETTEROFCREDIT = 6 EXEMPTION Q 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E I-i fll.n <br /> TJ41S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTFUDAYNEAR <br /> LOCAL AGENCY USE ONLY — <br /> COUNTY# JURISDICTION# FACILITY# Vrti' <br /> : q y U g <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL r I J <br /> //VV11�( I W' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SME <br /> IORMMION FaRomYs7A- <br /> �' <br /> FORMA(5-9t) <br />