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STATEOFCAUFORMA STATE WATER RESOURCES CONTROL BOARD `� o 611 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOp EACH F GLITY/SITE ' e 4roew^ MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANEN TE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSAOR FACILITYNAME I I_D � � NAMEOFOPEgATOfl ADDRESS I V 1 f � EAgE37 CROSS TREET PAgCEU(OPrpNgq CIT'NAME (� /� 9TATE ZIP CO E� SITE PHONE N WITH DE TO INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP E:] LOCAL-AGENCY 01 COUNTY-AGENCY' 'Ii wmer cl UST Is a publicagency, DISTRICTS' 0 STATE-AGENCY' ED FEDERAL-AGENCY' ;name oT Su rvkor of dNbbn,eeclbn,or office which operates the UST TYPE OF BUSINESS O t GASS STATION the fall0awlnB 2 DISTRIBUTOR O ✓ IF INDIAN IOF TANKS AT SITE E.P.A. 1,D,0 YgmmnaV, 0 3 FARM Q 4 PROCESSOR 0 5 OTHER Ofl TRUSTVLgNOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON ISECONDAR DAYS: NAME(LAST,FIRST) PHONE of WITH AREA CODE Y)•OptlODel DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CAI.--. ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ hoxbioEba Ie INDIVIDUAL 0 LOCA4AGENCY 1ST STATEAGENCY CIN NAME CORPORATION ED PARTNERSHIP Il COUNTY-AGENCY O FEDERAL-AGENCY STATE ZIP CODE PHONE A WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box biMbale ED INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY CIT'NAME 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 n questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓box bbOkate L—J t SELF-INSURED =2 GUARANTEE 9 INSDRANGE C7 5 LETTEROFCREDIT ED 6 EXEMPTION g9 OTHER O4 SURETY BOND � 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: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURYAND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) =C�WNEFI'S DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY r COUNTY# �' JURISDICTION # FACILfTYtl LOCATION CODE -OPTIONAL CENSUS TRACTt�GPTONAL S!, SUPV SO -DISTRIC CODE -poTA7A/1( THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OROR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(M) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR00731A7 r