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STATE OF CAUPORNIA i STATE WATER RESOURCES CONTROL BOARD L ' I � UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ./11/• COMPLETE THIS FORM FOR EACH FACIURYISRE �•a•�" MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SIT ONE REM 0 2 INTERIM PERMIT F-1 A AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAO FACILI AM NAME OF OPERATOR ADDR SS ,a /T If 5 RO S� PARCELY(OPrN)NAI) CITY NA �!/✓�!//' STATE ZIP y— 71 SITE PHONE s WITH AREA CODE CA (✓^ /D BOX TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP LOC L'C SENCV 000UNTY-AGENCY' O STATE AGENCY' O FEDERAL-AGENCY' If owner of UST Is a public agency,wrrpl9e the lollowing:name of Supervisorofdiwiso section,or office which operates the UST TYPE OF BUSINESS 0 t GAS STATION 2 DISTRIBUTOR � gESERVATDION a OF TANKS AT SITE E.P.A. I.D.a(aplianal) 3 FARM O A PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boaulrokale Q INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY CORPORATION 0 PARTNERSHIP COUNTYAGENCY Lj FEDERAL AGENCY CITU NAME STATE ZIP CODE PHONE M WITH AREA CODE III, TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa b inEicate Q INDIVIDUAL LOCAL-AGENCY E-1 STATEAGENCV (]CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-F4]- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED ✓ boa oodkale E=1 I SELF INSUREDGUARANTEE I� 3 INSURANCE A SURETY BOND [=)5 LETTER OF CREDIT 6 EXEMPTION Q 99 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.O II.D III.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNfTV u JURISDICTION X FACILITY r LOCATION CODE -OPTION CENSUS TRACT -OP. O(J4L SUPVISOR STRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM AWN) j FOROW3I497 sees, seer