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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONT ROL BOARD <br /> FORMA <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- �ed cs <br /> �t <br /> -,tea <br /> ACILITYISITE <br /> MARK ONLY E] 1 NEW PERMIT COMPLETE THIS FORM FOR EACH F •�.{.���„' <br /> ONE ITEMCLOSURE❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> FACILITY/SITE INFORMATION <br /> ❑ 2 INTERIM PERMIT El 4 AMENDED PERMIT I. &ADDRESS-(MUST BE CO 7 PERMANENTLY CLOSED SITE <br /> EI] 6 TEMPORARY SITE <br /> D13A ORFACILITY NAME COMPLETED) <br /> ADESS , - ✓j i n NAME OF OPERATOR <br /> DR �f g /VV'Ir� <br /> � Zf NEARESTCROS SRr T <br /> CITY NAME ���� r/• �-- FARCE Lp(OPTIONALI <br /> U � STATE <br /> ✓ Box QIP Cj�pE <br /> ITER NE#WITH EA COD <br /> TO INDICATE [�CORPORATION <br /> INDIVIDUAL 0PARTNERSHIP Ell LOCAL-AGENCY � � <br /> TYPE OF BUSINESS L-1 COUNTY-AGENCY <br /> ❑ 1 GAS STATION 2 DISTRIBUTOR DISTRICTS L] STATE-AGENCY FEDERAL-AGENCY <br /> [� 3 FARM 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.# <br /> 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> FrRSr} I !'QPlranalJ <br /> EMERGENCY CONTACT PERSON (PRIMARY} <br /> DAvs: NAME{LAsr, EMERGENCY CONTACT PERSON (SECONDARY _o <br /> U PHONE#WI AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) �L- <br /> 290C) DAYS: NAME{LAST,FIRST} } phonal <br /> II. PROPERTY OWNER INFORMATIPHONE#WITH AREA CODE <br /> NIGHTS: NAME{LAST,FIRST} <br /> NAME <br /> CL1L3E <br /> ON- MUST BE COMPLETED ' <br /> CARE OFADDRESSINFORMATION <br /> MAILING OR STREET ADDRESS G� -sem <br /> r <br /> r �/� _ ��� r�7r ✓ boll DIVfDUAL <br /> CITY N MA E L / TA CORPORATION LOCAL-AGENCY STATE-AGENCY <br /> �Qi���-i1L- /1,,.- L� PARTNERSHIP �]COUNTY-AGENCY/'� STATF� ZIP COD L� FECERAL-AGENCY <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) PHONE#WITH AREA CODE <br /> -! <br /> NAME DF OWNER <br /> 0�re/«/ �C,� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> � / <br /> �� V_- — �},�� ✓box�indcate INDIVIDUAL <br /> Cl E !/ `��/ �,[_] �CORPORATION C7 LOCAL-AGENCY 0 <br /> Cl PARTNERSHIP []COy,AGENCY STATE-AGENCY <br /> [�] <br /> STA ZIP CDdE FEDERALAGENCY <br /> - PHONE#WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if uestions arise. <br /> TY(TK) HQ [4E4 - 1. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓5es bindlcale -::] 1 SELPQI_:_C <br /> 5 LETT€-_:CREDdT L2 GUARANTEE [�j 3 INSURANCE <br /> =6 EXEMPTION Q 99 OTHER 4 SURETY BONE) <br /> FVL LEGAL NOTIFICATION AND 13ILUNG ADDRESS Legal nolikatlon and billing will be Sent 10 the tank owner unless box I or II is checked, <br /> OC-CKONE BOX INDICATING W Il ABOVE ADDRESS SKULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING; <br /> I'l❑ Ii.❑ lil.L❑ <br /> THIS FORM HAS BEEN COMPLETED ONDE PENALTY OF PERJURY,AND TO THE BEST OF MY KNOYVLEDGE,15 TRUE AND CORRECT <br /> AFPLACANT'S NAME{PRWTED&SK>iVATUREJ APPLICANTS TITLE <br /> DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 9 j JURISDICTION# F � <br /> LrX`,AT1D#+Cill •OPTilC�NSU TRA OPTIONAL <br /> �5. <br /> j , �2z7SUP15TRSCTCODE _OPTIONAL <br /> C) � / 3` <br /> THIS FORM MUST 13E ACCOMPANIED BY AT L11)OR O PE T APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> ! O� J 2- FORt103JA5 <br /> r 11 <br />