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• <br /> �younccs <br /> STATE OF CALIFORNIA Ar r cO. <br /> STATE WATER RESOURCES CONTROL BOARD W , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA :s , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT [g 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E�] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS A NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �?vG �Tca CA S2 v �a <br /> ✓BOX CORPORATION El INDIVIDUAL 71 PARTNERSHIP E::]LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 0 owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS BVI t GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER T OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> 6DVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE D Y : NAME(LAST,FIRS PHO #WITH AREA CODE <br /> 0 Z�4c�sGK .2o J- �+/v� > - -352 <br /> NIGHTS: NAME(QST,FIR I PHONE#WITH AREA COD TS: NAME(LAST,FIRST) q PONE#WITH AREA CODE <br /> �jf <br /> gaLjI <br /> �L v V <br /> II. PROPERTYGSOWNER INFORMATION-(MUST BE COMPLETED) VI/ <br /> a <br /> E CARE OF ADDRESS INFORMATION <br /> E 5, T J�1J►p <br /> MAILING OR STREET ADDRW ✓ box toMote INDIVIDUAL LOCAL-AGENCY = STATE-AGENCY <br /> =CORPORATION PARTNERSHIP COUNTY-AGENCY aFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE#WITH AREA CODE <br /> C*- e,4 o - L 79' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> ?E OF O NER CARE OF ADDRESS INFORMATION <br /> VAUQ <br /> MANG OR STRUT ADDRESS v1 box to indicate 0 INDIVIDUAL �LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ME STATE ZIP CODE PHONE#WITH AREA COD <br /> .�s-� <br /> j 4.4 <br /> �s zc <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate t SELF-INSURED O 2 GUARANTEE =3 INSURANCE =A SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 6 CERTIFICATE OF DEPOSIT Cl 10 LOCAL GOVT.MECHANISM = 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 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TAN W R'S NAME( NTED&SIGNATUR TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> o Ik �� �i�- <br /> IF <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT 1&(1)OR MORE PERMIT APPLICATION- FORM B,UNLES IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM'. THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />