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• <<'gouN STATE OF CALIFORNIA CO s STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLEIt IHIS FORM FOREAC 'FACILIrYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ( Q L I. FACILITY/SITE INFORMATION & ADDRESS - IMUST RE rOMPI FTFm DBA OR FACILITY NAME NAME OF OPERATOR v dam-- M STREET ADDRESS / ADDRESS fj,G(/• NEAREST CROSS STREET PARCEL It FORT 4 % Off" VF GflwaQ_ 5 G CITY NAME - CITY NAME STACEA ZIP CODE S. E PHONE # WITH AREA CODE COUNTY -AGENCY -D I� FEDERAL -AGENCY CITU NAME' STATE ZIP CODE ✓ R3x TO INDICATE ORPORATION E::] INDIVIDUAL O PARTNERSHIP E::] LOCAL AGENCY Q COUNrRAGENCY STATE AGENCY Q FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR 1 E=✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optimal) ❑ 3 FARM 0 4 PROCESSOR ❑ 5 OTHER VA ORRESERTION TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) —I D 3 — / NIGHTS: NAME.(LAST, FIRST) P)ONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) II. PROPERTY OWNER INFORMATION - (MI1ST RF CnMPI FTFn1 NAME • CARE OF ADDRESS INFORMATION M STREET ADDRESS / ✓ IIndicateINDIVIDUAL = LOCAL -AGENCY Ij STATE AGENCY (/," ,. CORPORATION O PARTNERSHIP 0 COUMKAGENCY I= FEDERAL AGENCY CITY NAME - STAT ZIP CODE ,7-212( PHONE # WITH AREA CODE COUNTY -AGENCY -D I� FEDERAL -AGENCY CITU NAME' STATE ZIP CODE III. TANK OWNER INFORMATION. (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION y . G MAILING OR STREET ADDRESS ✓ bo Indicate I� INDIVIDUAL 0 LOCAL -AGENCY L STATE -AGENCY ,7-212( CORPORATION I� PARTNERSHIP COUNTY -AGENCY -D I� FEDERAL -AGENCY CITU NAME' STATE ZIP CODE ONE # W H AR CODE p IV. oVAt1U UY tUUALILA IIVN U�L Ftt ACCUUNT NUMBER - Call (916) 323-9555 If questions arise. TY (TK) HO 1 47- � V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ W, 0hdtale L] I SELF-INSURED O 2 GUARANTEE Q 3 INSURANCE L__1 4 SURETY BOND EJ 5 LETTEROFCREDIT =] 6 EXEMPTION F-1 N 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 BO% INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. [--]II. Iyy III, THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANDC ORRECT LUL.AL AUtNL Y UDt UNLY COUNTY # JURISDICTION # ��FACILITY # LOCATION CODE OPTIONAL � ��__�� ///__ff��,,_,�_�//((5 ��////..{{��[[/�� t7 J, CENSUS TRACT# -OPTIONAL S ISOR DISTRICT —CODE -OPTIONAL �/ Vc a Z_— z 3. za THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONI Y FORMA (12-57) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TA LAT NS 0 40.