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�yOVRClS STATE OF CALIFORNIA s STATE WATER RESOURCES CONTROL BOARD W der a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �s . COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED,SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT W TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMEI NAME OF OPERATOR �Ay s M IN MAP_1<E7r Z'4y 4 MAP- m 1 L2A-CH ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 3300, W65T L-1gA)F- ALPINE I I _7 - DSD-3 �- CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE STOCK Tont CA Cfs7Z0(0 1 209 - 46(o-/682. ✓BOX 0 CORPORATION [INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY0 STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS N owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR RESEIRVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE M c I LRAT14 109 -462 -- 81 o-- NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Me IL_IZAJA 2-D9- 9-73 - 'f?83 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 7A e iMM&R- Me- I L2>4TI� MAILING OR STREET A/DDRESrISI V S n n ` ' ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY 16105- / IA`V V IE 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 57o C K?o^) C4 q 5 20(, Zoq —4-(,Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 3A- M&W- M G L'(z'6cT 4 MAILING ORRSTREET ADDRESS �/ ✓ boxiolodicate INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY IROS wV /V QP,I OF 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE 5700 _rCVQ C� 015206 Z0q- 46Z- 830 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ [41-4-l-1012-14 16912-1-7_ V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 8 EXEMPTION 0 7 STATE FUND 8 STATE RIND b CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.� III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER' M (PRINTED (GNAT E) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL'AAN6 USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJWRAGE TANK REGULATIONS / — v rafr 7 /C y