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`/ `...• e6ou,+ a co <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM <br /> C"I COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA)/Oj7�FACJL,ITY NAML NAME OF OPERATOR <br /> ADDREPS G✓l ILrU/'wv,-,_,•W[` v NEAREST CROSS STREET PARCEL$(OFONAL) <br /> CI N E STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> v BOX <br /> CA <br /> TO INDICATE (]CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY D COUNTY-AGENCY O STATE-AGENCY O FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 OAS STATION Q 2 DISTRIBUTOR E--] <br /> I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(WliunW) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q 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) PHON ITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W10indicale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREETADDRESS ✓ bux b indicate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION (] PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY 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-T-41- Z y �(o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bin&.&. 0 1 SELRINSURED GUARANTEE 3INSURANCE O 4 SURETY BOND <br /> I=5 LETTER OF CREW E4e 6 EXEMPTION 99 OTHER <br /> A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# �'�'T JURISDICTION# FACILITY# <br /> � PG vrvt� b 1 _ I/ _ <br /> LOCATION Cq -OPTIONAL CENSUS TRACY -OP�Nf( SUPVISOR-DISTflIC CODE -OPTIONAL <br /> U L3 M 3 Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A5 <br />