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/V,4.44E CtiCj -fCryeAA <br /> • .OUR e.4 <br /> • STATE OF CALIFORNIA AP' CO <br /> STATE WATER RESOURCES CONTROL BOARDJibm <br /> UNDERGROUND STORAGE TANK PERMIT A li*T-- y $S Q AIYH <br /> ERVICE <br /> •/—Jr COMPLETE THIS FORM FOR EACH FACILRY/SITEi_ <br /> ��11 I� <br /> MARK ONLY u t NEW PERMIT 3 RENEWAL PERMIT CHANG A N MANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT �_1<15 <br /> TEMPORARY SITE CLOSURE <br /> I. FACILITYI OMPLETED) <br /> DBA 0 ILITY NAME r� ��NEARESf <br /> M OPE T R <br /> ADDR �— - — CROSS STREET FAHUFL#(OPTIONAL) <br /> CITY NMv1E STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ---_` CA <br /> ✓ BOX <br /> TO INDICATE F-1 CORPORATION DIVIDUAL F__� PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: E(LAST,FIRS <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODFII. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> OafAq 44& <br /> MAILING RS REETAD RESS ✓ box to indicate DUAL E::] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NA 1 L^— yr ✓�'' ST ZIP CODE PHONE#WITH AREA CODE <br /> G� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate NDIVIDUAL <br /> /►� // �., LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> Y(TK) HQ 14 14I- <br /> V. <br /> I- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate SELF-INSURED E] 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> L_�:] 5 LETTER OF CREDIT 6 EXEMPTION OTHER 2T&6 rU <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.E] II.[::] III. <br /> THI RM HAS BEEN COMPLETE NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AP ICANT'S NA (PRINTED& I R I APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> � - 3 <br /> L Al_AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> X13111714 1 <br /> - - --- - - - <br /> LOCATION CO E OPTIONAL CENSUS TRACT# -OPTI AL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR TION ONLY. <br /> FORM A(1291IFILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ��—�� tgnL� FOR0033A-R6 <br />