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0 < <br /> STATEOFCAUFORNIA ,` '� <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> �� ': <br /> //�I UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA :� ,,, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ��tPOnY�� <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Ej 5 TEMPORARY SITE CLOSURE Q J <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> OBAORFACILITY NAME / NAME FOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> cyo GIn �aSon <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> mC,.k�- C5 CA 45336 <br /> T 1NDICA <br /> 0TECORPORATION O INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' ID STATE-AGENCY' I=) FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •N owner of UST Is a public agency,mnplele the folbwing:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 10 OF TANKS AT SITE E.P.A. I.D.s ropllanal) <br /> 0 3 FARM 0 4 PROCESSOR 0 RESERVATION 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST.FIR TI PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> �.Y�.sO•� Inn 07 S- <br /> NIGHTS' NAME(L T.FIRST) A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> NI6H4 yrr 4 rilC 3a _9 p64r <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �j O✓f <br /> MAILN ORST TADDRESS ✓ box bbdbab = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> D � (�CORPORATION 0 PARTNERSHIP cOUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAMEST,q TE ZIP CODE PHONE a WITH AREA CODE <br /> e✓LCcI cCe �'y5/ � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFeWNEFk CARE OF ADDRESS INFORMATION <br /> vS <br /> MAILING RR STREET ADDRESS ✓boabildbato 0INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> v O 8ro r yy [__1 CORPORATION E=j PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NACODE PHONE s WITH AREA CODE <br /> cn STA ZIP_C_k x 9 LI5 L c) <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- D 2 R <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmbbtlbate O I SELF-INSURED 2 GUARANTEE O D INSURANCE (]4 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION I=aB 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: L Q II.[::] III. <br /> ae- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY III JURISDICTION* T _ FACILITY# CL)-SIO %-1 <br /> 13117 <br /> 3 � f L <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL 3Zb 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM Br UNLESS THIS IS A CHANGE OF SITE IIgOflMATION o11 (}- <br /> OWNER MUST FILE THIS FORM WIT <br /> FORMA(Y93) H THE LOCAL AGENCY IMPLEMENTING THE UNDEflGROUTORAGE TANK REGULATIONS <br /> • F `T' <br />