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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO <br /> SED SFIV <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) bhp <br /> DBAOR FACILITY NAME NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELP(OPTX)NAL) <br /> CITYN MEc STATE <br /> ZIP SITE PHONE a WITH AREA CODE <br /> v BoxJICA <br /> TO INDICATE CORPORATION O INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY 0 COUNTYAGENCY' <br /> N owner of UST Is a DISTRICTS' (]STATE-AG�CY' O FEOEML-AGENCY' <br /> Pubic agency,complete the following:nano W Supervisor of divisbn.NFIIpII,or oNke which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.D.a TaptAm D <br /> 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION <br /> D OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE N04TS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED cc o2 <br /> CA OF KESS INFOR TK1N r ' 1 <br /> W { ( 1 <br /> MAILING OR <br /> CSTR ET DRE S. _ Ooxb GlMow D INDIVIDUAL O LOCAL-AGENCY STATE-MiENC4Y <br /> /l��W_ -C STPDRATION 0 PARTNERSHIP O COUNTYAGENCY (]FEDERAL-AGENCY <br /> NAME STATE ZIP P4 E a W TH AREA CODE <br /> 3 - <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S lit. <br /> MAILING OR STREET ADDRESS ✓OaRIDIMIc41e INDIVIDUAL I1 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP O COUNTYAGENCY ED FEDERALAGENCY <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 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUSTBECOMPLETED)—IDENTIFY THE MMOD(S) USED <br /> ✓ bo�biMkale = I SELFINSURED O 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> EJ 5 LETTER OF CREDIT O 6 EXEMPTION 0 99 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: I. III. <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 A SIGNED) OWNER'S TITLE DATE MONTHRDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION a FACILITY s <br /> 317 16a KL 19,1 171 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL .a U D SUPVISOR-DISTRICT CODE -OiPTIONAT. <br /> p� / <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM AA((39Q3) _ ,, , �{ FORA MG ' <br />