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C- F <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMACOMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY O I NEW PERMIT O11 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT (J a AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAMEOFOPERATOR <br /> ! I -"O'y <br /> ADDRESS NEAREST CROSS STREET PARCF1alOPTONAU <br /> CITY NAME ` G STATE ZIP SITE PHONE a WITH AREA CODE <br /> 'r CA <br /> TO DI A /VY TE O CORPORATION O INDIVIDUAL O PMTNEASMP O LOCAL-AGENCY ED COUNTY-AGENCY' O STATE-AGENCY' O FEDEMLAGENCY' <br /> DBTIICTS' <br /> If owner of UST Is a pubic agency,cor Pete the folloe":name of Supervisor of division.section,or office whch operates the UST <br /> TYPE OF BUSINESS O ( GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIAN <br /> s OF TANKS AT SITE E.P.A. I.D.a(cpNanaf) <br /> Q 3 FARM Q e PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMER ENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(I AST FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Il. PROPERTY OWNER 6ORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa blMNate Q INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION M PARTNERSHIP I1 COIINTYAGENCY = FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATIO MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bYebaM INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION PARTNERSHIP COUNIYAGENCY O FEDERAL AGENCY <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 it questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor bilMi[ate O I SELF-INSURED , O 2 GUARANTEE 3 INSURANCE O A SURETY BOND <br /> =5 LETTEROFCREDIT 6 EXEMPTION 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.Q 11.E—] 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY i <br /> yq 11, 11111 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP7IOAML SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK)NS <br /> FORM A(3i93) /, ,J� <br /> -amFOROMM R7 <br /> ±► AQ <br />