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o rP ,�{/�'4 764 <br /> /-C> y/y <br /> ITATi OF CAUPORMA � ( d 3 <br /> STATE WATER RESOURCES CONTROL BOARD /V 3 7 <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA o, ,, C( <br /> C/ COMPLETE THIS FORM FOR EACH FACILIfYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ J RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T RMANENTLY CLO D SIT <br /> ONE REM ❑ 2 INMRMYPERMTr ❑- 4 AMENCEp PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILrrY/SJTE INFORMATION III ADDRESS-(MUST BE CO PL D) <br /> OBAORFACILI NAME N OFOPERATOR <br /> x. <br /> ADDRESS NEAR TCROSS STREET PARC <br /> S <br /> CITY NAME S TE ZIP CODjF SITE PHONE a WITH AREA CODE <br /> cA 9s <br /> TINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP l LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDEMLAGENCY' <br /> DISTRICTS* <br /> 3 wmer d UST Is a pubAF2g`enry,mimlele IN kMawN3:nanw of guperviwr Yon.w ion,W Olin which opwslw IN UST <br /> TYPE Of BUSINESS O I GAS SW10N.- UTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.0 r[plmeo <br /> D FARM s PROCESSOR 5 OTHER RESERVATION <br /> Q [❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> �1 YS: N E(LAST,FIRST) PHONE WI=H AREA DE DAYS: NAME MST,FIRST) PHONE a WITH AREA CODE <br /> -(/J,(^J NIGHTS: NAME(LAST,FIR PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ L mm*m Q INDIVIDUAL AL-AGENCY Q STATE AGENCY <br /> Q CORPORAPON Q PARTNERSNPIn COUNTY#GENCY Q FENRALAGENCY <br /> CITY NAMEgTATE ZIP CODE ����/ PHONE a WITH A POPE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPL ED) //✓ <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> J�V.t-^W-lX• A'S <br /> MAILING OR STREET ADDRESS ✓ Em UirdinM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4—T47- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ ppA py�y Q I SELF INSURED Q 2 GUARANTEE Q 5 INSURANCE Q A SURETY ND <br /> 0 5 LETTEROFCREDIT 0 5 EXEMPTION Q w OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unl s box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. 1. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISUE AND CORRECT <br /> OWNER'S NAME(PRINTEDB SIGNED) OWNER'S TITLEDATE, MONTHD1YfYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY <br /> # / ' /� / JURI�# F a <br /> LOC TpN CODE -aP NAL CENSUS TRACT# .OPTIONAL SUPVISOR-DISTRICT CODE - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION- FORM Br UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA79M <br /> FORM A(SNS) ( ( FOFAM1 87 <br />