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aebou. ; u <br /> STATE OF CALIFORNIA ll � <br /> STATE WATER RESOURCES CONTROL BO) 0 w ss o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICA • FORMA ;m <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY 'USESITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY"t"M E �� 1 NAME OF PERATOR Sho <br /> 0 e Ick Q ©n5 rV c'I�f c <br /> ADDRESS NEARE5T ROSS TREET PARCEL#(UPI ZONAL) <br /> eo W 7d <br /> CITY NAME <br /> STATECA ZIP S 3 66 17 PMHONEC WITHAREA��� <br /> TO v BOXINDICATE O CORPORATION INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> AN 1TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR I= R SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM O 4 PROCESSOR5 OTHER I OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) ONE#WITH AREA CODE I DAYS: NAME(LAST,FIRST) <br /> 2 s99- bs <br /> NIGHTS: NAME(LAST,FIRST) PHONE# ITH AREA CODE NIGHTS: NAMEtLAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CA✓FMADDRESS INFORMATION <br /> S1oake a SoO5 o nc ocke� <br /> MAILIN ^ EEDox 0lnd IINDIVIDUAL LOCALAGENCY STATE-AGENCY <br /> 1 �� 0 CORPORATION PARTNERSHIP CO <br /> / UNTY-AGENCY FEDERAL-AGENCY <br /> CITY NA STATF. H ARE DEY <br /> on C� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> .� Qs <br /> MAILINGOR STREET ADDRESS ✓ box rdkaW = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> E-1 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY E71 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It 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-r4—]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blaAkaIA 0 1 SELF-INSURED [�71 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION D 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# / ILffY# SHOO-K S6 <br /> � CZS a 5 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTfl ICT CODE -OPT <br /> 05 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-81) FOR 5 <br />