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STATE OFCAUFOMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FOR A / °• '�' •p <br /> COMPLETE THIS FORM FOR EACHFACILNYISITE �� �Z "V` •'c�„a,,,,.' ” " <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION O /-PER ANENTLY CLOSE <br /> ONE ITEM O 2 INTERIM PERMIT O A AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACIM/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREFTPARCELI <br /> CITY NAM STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CA <br /> T NDICATE INCORPORATION OINDIVIDUAL PARTNERSHIP O LOCDISTALA'ASNCY {�Jr1 WNfYAGENCv• OSfATE-AGENCY• � FEDERAL#GENCY• <br /> 'N owner d UST Is a public agency.aNryloe Na Wowing:name d Supervwur d division,section.a once"ich <br /> owatea the UST C <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.•(apMa3W) <br /> RESERVATION <br /> Q 3 FARM 0 s PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH A7A CODE DAYS:NAME(LAST•FIRST) PHONE a WITH AREA CODE <br /> NIG„ : NAME(LAST,FIR PHONE a W TN REA CODE NIGHTS: NAME(PART,FIR�, PHONE a WITH AREA COD <br /> �7 - 76 -17 , <br /> 3 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME Lt ! CARE OF ADDRESS INFORMATION <br /> C�lfr' <br /> MAILING OR STREET ADDRESS,, ' ✓tetbinlicas INDIVIDUAL [� AGENCY (]STATE-AGENCY <br /> 2 KJ Q CORPORATION PARTNERSHIP LUKOUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAMEczSTATE ZIPCODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> e <br /> MAILING OR STREE ADDRESS ✓ (] INDIVIDUAL Q� L/D(`,AL.AGENCY O STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP Ua"FADUNTY.IGENCY (] FEDEMLAGENGY <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 F4-F4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bbdNda I SELF-INSURED Q 2 GUARANTEE Q 3 L5URANCE O A SURETY BOND <br /> D 5 tETTEROFCREDIT s ExEMPnON O 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: L IL 5;?-�111.� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KJVOWLEJGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNERS TITLE DATE MCPTHVDAYNEAR <br /> H <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION i FACILITY t'7 l <br /> a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INIFIDIIIIIIIATI10114 ONLY. <br /> OWNER MUST FILE THIS FOri" "-TH THE LOCAL AGENCY WPLEMENTING THE UNDERGRO'.. . STORAGE TANK REGULATIONS FCRDW3MT/ <br /> FORM A CAM <br /> y <br />