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i • QMI <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMACOMPLETE THIS FORM FOR EACH FACILITYISITE CA,y <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ ❑ ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR,D—f NA:)orVi NAMEOFOPERATOR <br /> caS <br /> ADDRESS TT �J'1 v' NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Ll N4 v &1 -1 ve-) <br /> CITU NA E STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> K-� ca ,5203 <br /> ✓ BOX <br /> TOINDICATE CORPORATION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TAN&VT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH ARE777 AYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbinEkxle 0 INDIVIDUAL 0 LOCAL-AGENCY I] STATE-AGENCY <br /> l�CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box a 0 INDIVIDUAL 0 LOCAL-AGENCY E-1 STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY (I FEDERAL-AGENCY <br /> CITY NAME 7_1 <br /> TATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 C 2 2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0I,&ale = 1 SELF-INSURED Q 2 UARAMEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETrEROFCREDIT a EXEMP ION ED 99 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.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR INTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# C.OT'y JURISDICTION# e/J FACILITY# <br /> STs�z vz <br /> LOCATION COD TIONAL CENSUS TRACT-OPTJON� SUPVISC ISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A5 <br /> i 0 ����� <br />