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r�!,o�ncts STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA , COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L] 7 PERMANENTLY CLO ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE L FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) E A FACILITY NAME NAME OF OPERATOR DBA OR 4 / 1 J ADDRESS N L EAREST CROSS STREET PARCEL 0(OPTIONAL) 7 (DO CITY NAME STATE ZIP C.00E SITE PHONE#WITH AREA CODE ICA ✓BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR Q ✓IF PNDIAN #OF TANKS AT SITE E.P,A. L D.#(optional) TION 3 FARM 4 PROCESSOR 5 OTHER (TRUST ANDS [� Q OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRS v J PHONE#WITH AREA CODE r AYS: NAME(LAST,FIRS PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WI{Tki AAFkGOQQE, NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FECERAL•AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION t :-ri IC�Sf-+wtfrz bH221 MAILING OR STREET ADDRESS I 6/ box to indicate i0 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY f aC j I"1 l�{2 4Il h! G7- Q CORPORATION Q PARTNERSHIP © COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE _ PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED 1,,2 tl Jry/ box to indicate 1SELF-INSURED Q2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT L 6 EXEMPTION Q 7 STATE FUND IQ 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER I=9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 0 It.[�] III. THIS FORM NAS BEEN COMPLETED ED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE)- -- TANK OWNER'S TITLE DATE MONTHiDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY#, LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL R'� �►f!8 `17 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)