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. < <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH F /SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN TLY CLOSED SRE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 50 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELA(OPTIONAU <br /> C17Y NAME —STATE C21P CODEsw/ SITE PHONE WITH AREA—CODE <br /> A <br /> TOINgCATE 0 CORPO N Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTYAGENCY —� <br /> DISTRICTS f� STATE-AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN j*OF TANKS AT SITE E.P.A. L D.t(option) <br /> 3 FARM 4 PROCESSOR RESERVATION <br /> ❑ (] Q 5 OTHER pR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE AWITH AREA GO DE GAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGFITS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Doi biMira(e ED INDIVIDUAL Q LOCAL-AGENCY O MATE-AGEWY <br /> Q CORPORATION Q PARTNERSHIP 0 CWNry-AGENCY =1 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boao0KI"w 0INDIVIDUAL 0 LOCAL-AGWCY STATE-AGENCY <br /> 0CORPORATION O PARTNERSHIP Q COUNrYAGENCY 0 FEDERALAGENCY <br /> CITU NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4-1-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> but mkau Q I SELF-INSURED 0 2 GUARAKrEE 3 INSURANCE <br /> D 5 LETTERGFCREDR 97 OTHER <br /> 0 6 EXEMPTION O a SURETYBOND <br /> O <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boz I's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL❑ M.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) - APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION a FACILITY 0 <br /> ® L 1 1 d I Kr <br /> LOCATION CODE .OPTIONAL CENSUS TRACTX -OPTIONAL SUPVISOR-DISTRICT CODG�-QPn0WAL <br /> O j C <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FORM33A5 <br />