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eew r STATEOFCAUFORWA i�' '� STATE WATER RESOURCES CONTROL BOARD eAy yq g UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA � COMPLETE THIS FORM FOR EACH FACILITYISITE °""°""�� ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE MARK ONLY ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS - -- NEAREST CROSS STREET PAACELx(OFfIONAL) 4-'�r CITY NAME STATE ZIP CODE _ SITE PHONE x WITH AREA CODE CA TOINOBCATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCALDISTRIAGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' II owner of UST Is a public agency,complete the lollowing:name of Supervisor of d"IDn,aemion,or o81ce which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.x(optimal) ❑ ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR I❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opllonal DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PNONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION. NAME , MAILING STREET ADDRESS ✓ bekblfMicate D INDIVIDUAL [_1 LOCALAGENCY STATE AGENCY OR (]CORPORATION 0 PARTNERSHIP D COUNTY AGENCY FEDERAL AGENCY CITY NAME STATE ZIP.CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicalo = INDIVIDUAL LOCAL STATE-AGENCY l�CORPORATION O PARTNERSHIP 0 COUNTY AGENCY � FEDERAL CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 44- -[—I �� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bindbale 0 1 SELF INSURED = 2 GUARANTEE O 3INSURANCE 4 SURETY BOND = 5 LETTEROFCREDIT O 6 EXEMPTION 0 36 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: I.❑ if.❑ H.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACTx -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORDN3A417 FORM A t"3) 0 •