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• • ooa e <br /> STATE OF CALIFORNIA " `'s^ <br /> STATE WATER RESOURCES CONTROL BOARD w� �. ,, <br /> n UNDERGROUND STORAGE TANK PERMIT PPLICATION- FORMA <br /> C.IISOXY�n <br /> COMPLETE THIS FORM FORE H FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM 2 INTERIM PERMIT O d AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE YS <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) L/ <br /> DBpQfi,FACILITY`ME '44 , n NAME OPERATOR �. / /� <br /> 40 <br /> ADD_I /LRSall•' NEAREST CROSS SvnTRE//ETG l//1`,j PAfiCELk(OPrpNAL) <br /> CITY NAME STATE ZIP CO � ITE PH NE#WITH AREA C DE . <br /> _fjCA Z1�Y]I SJCy21/ <br /> ✓ BOX <br /> TO INDICATE D CORPORATION EVINDIVIDUAL O PARTNERSHIP 0 LOCAL AGENCY 0 COUNTY-AGENCY O STATE AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION E__] 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANIy�T SITE E.P.A. I.D.#(apliaral/ <br /> RESERVATION c•.TJl <br /> = 3 FARM O d PROCESSOR E::] S. OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> fl. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Indicate D INDIVIDUAL E71 LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED QWN)rR� n O% / CARE OF ADDRESS INF�[—RM')ATI0 . <br /> (�Nn <br /> MAILI OR STREADDR <br /> TESS ✓ hmbirAkate aN- <br /> D , 0 / D� O INDIVIDUAL I= LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION <br /> i� 0 PARTNERSHIP 0 COUNrYAGENCY L-1 FEDERAL-AGENCY <br /> CITVN E V ST/bTE- ZIPCDE ��OP NEv WIT AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if question rise. <br /> TY(TK) HQ F41-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOM ETED)—IDENTIFYTHEMETHOD(S) USED <br /> ✓box M indicate 1 SELFINSURED L:1 GUARANTEE [__1 3 INSURANCE d SURETYBOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION 0 W 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 A BILLING: I.❑ II.❑ It.IV <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYY'EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 341/ 7- <br /> -LO—CA I]ON CODE -OPCyJAAC <br /> L CENSUS TRT#-:OPIIODNAL SUPVIS -gISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE <br /> II ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0035A 5 <br />