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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AI� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY L.- 1 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION = 7 PERMANENTLY CLOSED SITE <br /> ONE REM CI 2 INTERIM PERMIT 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME - �^ NAMEOFOPERATOR <br /> ADD E33 p NEARE CR0938TREET PARCEL#OPTIONAL) <br /> �O _ <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 4:1 Box CA 9 Z D �0 - bj� 64 <br /> TOINDCATE 0 CORPORATION D INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATEAGFNCY' O FIEDERALAGENCY• <br /> gSTRICTS' <br /> If owner IN UST M a public agency,wrrp]Oe the following:name of Supervisor o1 tlNibn,section.w office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.a(optimal) <br /> RESERVATION <br /> 3 FARM <br /> 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> MGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /�Jo <br /> MAILING OR STREET ADDRESS ✓Ear bENkW 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ST_ 0 CORPORATION D PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> on ,STs/U 2Eq <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bar b EbEMe =INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> G1✓• �- O CORPORATION 0 PARTNERSHIP O COUNTYAGENCY 0 FEDERALAGENCY <br /> C NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [414- -[1_LTT:[—I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box m WiPite 0 I SELFINSURED 0 2 GUARANTEE 3 INSURANCE E:j 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 8 EXEMPTION 0 0 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: 1.0 U.V III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY C JURISDICTION It FACILITY- <br /> LOCATIONCODE -OPTIONAL CENSUST i-OPTIONAL SUPVL90R-DISTRICT CODE -OrPTIOW <br /> Z3- Z 32v I I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORAiATIDA ONLY. <br /> FORMA 13.93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORbel3AA1 <br />