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MOVED i STATE OF CALIFORNIA n Qg 3STATE WATER RESOURCES CONTROL BOARD U06JR�R�O n GE TANK PERMIT APPLICATION • FORMA ENVIRONMENTAL H >„ p;gmjj/SERV1Q94LETE FORM FOR EACH FACILRY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILIJY NAME I NAME OF OPERATOR AACD RESS NEAREST SS STREET PARCEL (OPTIONAL) 41—CITU 'AME STACEA ZIP O E�� SITE PHONE;�1/�yl�AREA CODE �l)rr O Lib ✓I80% TOINIIICATE CORPORATION INDIVIDUAL O PARTNERSHIP OCA4AGENCY 0 COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AG Y DISTRICTS TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS SITE E.P.A. I.D.#(optional) ❑ 3 FARM O 4 PROCESSOR 5 ORESERVATION THER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ONE 0 WITH ABEA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAM;, CARE OF ADDRESS INFORMATION MAILIN OR/S'TjJ�EET ADDRESS ✓hoz blMkale 0 INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY _ I - d ELI CORPORATION Q PARTNERSHIP 0 COUNTY.AGENCY 0 FEDERAL AGENCY CI NAME STATE ZIP CODE PHONE it WITH AREA CODE C� s3'3Z.v - FSSZZI III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNS CARE OF ADDRESS INFORMATION V MAILING OR STREET DRESS ✓ boz blMlcale 0 INDIVIDUAL 0 LOCAL-AGENCY I]STATE-AG CY CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALA ENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ hoz bmdicaIa D I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY NO D 5 LETrER OF CREDIT 0 6 EXEMPTION 0 93 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.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE OPTIONAL (CENSUS TRACT# OPTIONAL L-� SUPVISOR-DISTRICT CODE -OPTIONAL O THIS FORM MUST BE AtCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION,ON Y. FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS IN 0 P/ FOR 33A R6