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cSpU�CCS .. <br /> STATE OF CALIFORNIA Ar P oO r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA .� . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOS D <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME f NAME D1PERATO /.AwA� MC !C 4 (!4 <br /> �A 5 MINI rV►Af2ka`"(` A ! 1 <br /> ADDRESS 3 3 O O WE 5T 1. AO E NEAREST CROSS N E7 PARCEL#(OPTIONAL)�50`3 2- <br /> CITY NAME r V STATE t'1 t'ZIP CODE SITE PHO--NTE#WITH AREA CODE <br /> 5ToCK Tof> CA <br /> Q� <br /> ✓BOX Q CORPORATION P 51NDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '9 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 1 GAS STATION a 2 DISTRIBUTOR a ✓IF INDIAN J#OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION h <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYf AME(LAST.FIRST) �n PHONE#yVITFI AREA CODEO DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGF1TxS:C ME LASKATHT.FIRST) ���"t ��F�NE#WITH AREA CODE � NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMP'L'ETED) <br /> NAME�A 7 1 ,•„A PLY ry,e- I t-�Tn Tq CARE OF ADDRESS INFORMATION <br /> ° MAILING OR STREET ADDRESS -` t/ box to induate `INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> q p5 NAS y D R.1 V1E Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NA E STATE ZIP C DE PHONE#WITH AREA CODE <br /> `jTocK-rotJ G4 52-04, z0q -4'412 -87-07 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER � Al fl kV M C_ I t 1QA_TP( <br /> MAILING CARE OF ADDRESS INFORMATION <br /> `Gw1JORtR1STREETADDRESSS�/ ✓ boxtondicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 14105 AIA V y D410F Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COD PHONE#WITH AREA CODE <br /> 51roC_KTaN qSZ©6 Z0q 4 6 2 eo� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4- -IOIZ14 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate i SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM 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: '.= 11.El 111.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED <br /> /&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL A6ENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1;� - <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST411)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORMTHE LOCAL AGENCY IMPLEMENTING THE UNDERGRO49TORAGE TANK REGULATIONS <br />