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MARK ONLY <br />ix.ous � <br />STATEOFCAUFORNIA <br />��� <br />s� <br />STATE WATER RESOURCES CONTROL BOARD <br />+` <br />° <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br />o� <br />' <br />• <br />J <br />CA <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />� °n„Y,r�� <br />BOX <br />TO INDICATE Q CORPORATION Q INDIVIDUAL IQ PARTNERSHIP Q LOCAL -AGENCY Q COUNTY AGENCYIQ STATE AGENCY' Q FEDERAL AGENCY. <br />MARK ONLY <br />O 1 NEW PERMIT <br />a 3 RENEWAL PERMIT <br />O 5 CHANGE OF INFORMATION <br />a <br />7 PERMANENTLY CLOSED SITE <br />ONE REM <br />O 2 INTERIM PERMIT <br />Q 4 AMENDED PERMIT <br />O 6 TEMPORARY SITE CLOSURE <br />ZIP CODE <br />I � 7 -7 <br />I. FACILITY/SITE INFORMATION & ADDRERR - (MAST RF rnMDI FTFm <br />ORA OR FACILITY NAME <br />r.. <br />NAME OF OPERATOR <br />ADDRESS" <br />NEAREST CROSS STREET <br />PARCEL #(OPTIONAL) <br />Q CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY Q FEDERAL AGENCY <br />^IOL <br />STATE <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE M WITH AREA CODE <br />J <br />CA <br />�C <br />BOX <br />TO INDICATE Q CORPORATION Q INDIVIDUAL IQ PARTNERSHIP Q LOCAL -AGENCY Q COUNTY AGENCYIQ STATE AGENCY' Q FEDERAL AGENCY. <br />DSTRICTS' <br />' It mner o(UST Is a public agency, W oplete the following: name of SUP9Neor of dNiebn. section, or office which operates the UST <br />TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR✓ <br />IF INDIAN <br />IN OF TANKS AT SITE <br />E. P. A. I. D. # (epricnal) <br />3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESE <br />TRVATION <br />Oq RUST LANDS <br />9 <br />CMCGCENCY muTAU oemnu . <br />�•••�••-�^- •� t�^erg^^v EMEHULNUY WNTACT PERSON(SECONDARY)- optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATInN . !MI ICT RF rne#DI CTOn1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓Dox biMkale Q INDIVIDUAL Q LOCALAGENCY Q STATE AGENCY <br />✓ box 0 Q INDIVIDUAL <br />Q CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY Q FEDERAL AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE N WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MI IST RF rnNADI GTGm <br />NAME OF OW NER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box 0 Q INDIVIDUAL <br />Q LOCAL AGENCY Q STATE "AGE NCY <br />CIN NAME <br />Q CORPORATION Q PARTNERSHIP <br />STATE ZIP CODE <br />Q COUNTY AGENCY Q FEDERAL AGENCY <br />PHONE # WITH AREA CODE <br />I . OWM Id Vr QV U ALIL.AL I I V N UO 1 D I UMAU C rtt AGUUUN 1 NUMOCH - hall (916) 322-9669 If questions arise. <br />TY (TI F•Q 44- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED <br />✓ boxbbtlb#p Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE IQ 4 SURETY BONG <br />IQ 5 LETTER OF CREDIT _ Q 6 EXEMPTION Q al OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. [:] II. [—] III. D '- <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LVVAL AUCNV T UJC UNLT <br />COUNTY # JURISDICTION # FACILITY* <br />m <br />LOCATION CODE - OPTNDNAL (CENSUS TRACT# - OPTIONAL 3UPVLSOR-DISTRICT CGDE-OPTIOAVAL <br />••••-•-•••�•••••-•-.........o.nrr.c..o1Ill UnnowncrcnmilArrUUATIII -rum ci, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (393( FOROW3AA7 <br />101 0 <br />