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a <br /> STATEOFCALIFORNA STATE WATER RESOURCESCONTROL BOARDUNDERGROUNDSTORAGE TANK PERMIT APPLICATION FORMA <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE PERMANENTLY CLOSED SITE <br /> ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �� <br /> MARK=ITEM [] <br /> NEW PERMIT ❑ e TEMPORARY SITE CLOSUREONE <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) 0ATOR -e <br /> OBAO ILITVINA�+7E� � ya� O� I ,PARCELp(OPTIONAL)' / NEAREST CROSS STREET <br /> ADOREZIP C <br /> ,.a ^ ^ SITE PHONE k WITH AREA CODE <br /> � <br /> /(C/(J` lX/V x STATE <br /> CITY NAME (�`A !GEV FEDERAL-AGENCY <br /> BOX INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY O <br /> TomOCATE O CORPORATION DISTRICTS ✓ IF INDIAN #OF TANOT SITE E.P.A. I.D.#(WlAonap <br /> ❑ RESERVATION <br /> TYPE OF BUSINESS 13 GASSTATIONO 2 DISTRIBUTOR O 4 PROCESSOR 5 OTHER OR TRU ST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> it. PROPERTY OWNER INFORMATION- MUST BECOMPLETED EOF ADDRES NFORMATION t<i(CWA- <br /> NAMy I� Tu I/ Indic Q IND UAL LOCAL-AGENCY 0 STAIIE-FEDERAL AGENCY <br /> MAILII OF STREET/ADpRE�&/� n_ ^.I., ./ RPORATION NERSHIP COUMy AGENCY Q FEDERAL <br /> L% LLI l/ ST E ZIP COD��^ O PHONE#WITH AREA CODEQ O <br /> CITY NAME CA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNERv'� <br /> pox gindicate E:] INDIVIDUAL O LOCALAGENCV �STATE-AGENCY <br /> MAILING OR STREET ADDRESS CORPORATION O PARTNERSHIP COON pMNTH AREACY OCODEEMLAGENCY <br /> STATE Zip CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 44 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THOS M IETHODES) USED O 4 suREn xx o <br /> O Ogg OTHER <br /> O 2 ARA EE <br /> 1 SELF INSURED E%EMPTON <br /> pax n indicate 0 5 LETTER OF CREDIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box II or II is eike❑d <br /> CHECK ONE eOx INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IDS TRUE ANDDIC TWDAVC AR <br /> APPLICANTS TITLE <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY F Fry# <br /> COUNTY# 10# /6 <br /> ✓-1-x—' SUPVISOR'IS RICT CODE -OP '7 r <br /> LOCATION COL] OPTIONAL CENSUS TRACT% )PD�'L <br /> FORM <br /> THIS FORM MUST BE ACCOMPANIED VT Al LEAST(T)OR MORE PERMIT APPLICATION• B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OONRLOY-, <br /> FORM A(5-91) • <br /> Wq-)rr4� 1 - <br />