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STATE OF CALIFO s#I0 •-' <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC - <br /> MAR 12 1993ATI <br /> COMPLETE THIS FORM FOR EACH FAOLITYIS►TEHEALI <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ RENEWAL PERMIT 5 CHANGE OF INFO RMAT"Q p �,�ry��ynESLOSED TE <br /> 1"CfFtYY� 1�Cf�VIIiGJ <br /> ONE ITEM ❑ 2 INTERIM PERMIT �AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) lJ <br /> DBA Of9ACILITY NA NAkgPF OPERATOR' <br /> ADDRESS NEA)PT OSSSTREET PARCEL 0(OPTIONAL) <br /> , 99 <br /> CI STATE IP CO SITE PHONE# ITH AREA CODE <br /> CABOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR Q ./ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECOND RY)-optional <br /> DAYS AME(LAST,FIRST) PHONE#WITH AREA CODED NAME( IRST) <br /> ate. 1 <br /> NIGHT NA AST, IRST) PHONE#WITH AREA CODE NI S: INJAM <br /> C _7.1 <br /> E#WITH AREA <br /> Gc <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMOF ADORESS INFORM <br /> fJ. r <br /> MAI R STREET // ? ✓ bo indicate Q INDIVIDUAL Q LOCAL-AGENCY TATE-AG <br /> 0 . ;D� <br /> CO O 3� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU ME ST ZIP CODE PHONE#WITH AREA CODE <br /> 9Q�az-�03 /o-sem 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NANIE-PF OWN R C OF ADDRESS INFORM <br /> TREd trate INDIVIDUAL LOCAL-AGENCY -AGEM V _ a� oRATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENYC <br /> Y <br /> CITY ME r--- Sj+�TE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 74F41_ c5O <br /> V. PETROLEUM UST FINANCIALSPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT Q 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.❑ it.❑ III. <br /> THIS FORM HAS BEEN COMPLE DER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP NTS NA (PRINTF &SIG TU ) APP ANTS TIj DATE MONTH/DAY/YEAR <br /> LOC AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 14,�(.p S / 7 <br /> l 5 5 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUSSIS •QISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION-'IFIO�RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />