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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3.nom' sc <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- ( R� d 2 1993 a D <br /> o <br /> LNVIRONMEN TAL HE w <br /> PEE <br /> �onN`� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE kJ <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 NEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0/1 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLE <br /> DBA FACILITY NA NA OF O RATOR <br /> 3 <br /> ADDRESS E CROSS STREET PARCEL#(OPTIONAL) <br /> CITY N OAESTATE ZIP CODE SITE PHONE#WITH AR A CODE <br /> 0010, <br /> CA <br /> ✓ BOX <br /> TO INDICATECORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN T TE E.P.A. I.D.#(optional) <br /> RESERVATON <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECOND Y).optional <br /> DAY AST,FIRST) PHONE#y WITH CODE � DA NAM AS 1 d0—Z '7�—�s,•3,/ <br /> NIGHT N (LAST,FIRS PHONE it WITH AREd(A,CODE NI TS�: NAM( ( IR �_ ��06 �� —G 3 L <br /> Zo <br /> fid _ rc l( a"',- j (> <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM E OF ADDRESS INFORMATION <br /> MAILc TADIS �� bx te INDIVIDUAL LOCAL-AGENCY <br /> © , Q TON S AGEN <br /> PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY —�- SjE ZIP CODE PHONE#WITH AREA CODE <br /> L�- 74.2—e,/,O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMF,,a OWNER OF ADDRESSINFORMATI N <br /> O" <br /> MA(EttGt,�q SHEET ADD S ✓box to indicate INDIVIDUAL LOCAL-AGENCY = ATE-AGE <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY S�tjE ZIO DE d PHONE#WITH AREA CODS <br /> 4 1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323--9555 if questions arise. cc co <br /> TY(TK) HQ _4 4 - p D <br /> V. PETROLEUM UST FINANCIAL PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate E1111 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION 0 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.D it.❑ <br /> THIS FORM HAS BEEN COMP )ED UNDER PENALTY OF PERJURY,AND TO THE BEST O�F MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ( <br /> A ANT'S NFjME(PRt(VTD 8 IGN R A (CANTS TITL G DA�� <br /> LOC L AGENCY USE ONLY L <br /> C�TY# � ^ JURISDICTION <br /> # FACILITY# I <br /> $1� <br /> 5 � IIII <br /> LOCATION CODEIONAL E SUS TRA T OI;NAL SUPVISOR- SANT CODE -OPTIONAL <br /> I Zz OIL <br /> THIS FORM MUST dE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY. <br /> FORMA(5-91) � � FOR0033A-5 <br />