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STATE WATER RESOURCES CONTROL BOARD C., STATE OF CAUFORNIA UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOWs' A a COMPLETE THIS FORM FOR EAC MARK ONLY ❑ NEW PERMIT ACILRY/SITEONE ITEM ❑ S RENEWAL PERMIT❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION ❑ I. FACILITY/SITE INFORMATION&ADDREO # AMENDED PERMIT ❑ B TEMPORARY SITE C OSURE T PERMANENTLY CL/ TE DBq OR FACILITY NAME - (MUST BE COMPLETED) V� ADDRESS 3 NAMEOFOPERATOR CITY NAME z od✓ NEAR ESTCROSS STREET /LPARCEL#(OPTIONAL) ` STATE �// d ✓ BoX ZI CODE TO INDICATE �CORPORATONCA 95.36 SITE PHONE#WITH AREA CODE INDIVIDUAL CJ PARTNERSHIP 0 LOCAL-AGENCY / TYPE OF BUSINESS 11 , „ STATION l� COUNrygGENCy L��I'%"`O ❑ 2 DISTRIBUTOq DISTRICTS 0 STATE-AGENCY 0 FEDERAL-AGENCY 3 FARM O # PROCESSOR ❑ ✓ IF INDIAN #OF TANKS AT SITE I P,A, I.D.# ❑ 1 OTHER OR TRUSTVLANDS (options/J Ai EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON Gt�R �PHONE#WITH AREA CODE (SECONDARY . NIGHTS: NAME(L, _ OgYS: NAME(LASFF, IRST) ) Optional PHONE#WITH AgEACODE 9y^ TS3 NIGHTS: "ML(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME MgILING OR STREET ADDgESS CARE OF ADDRESS INFORMATION ✓Lox b Indk,ta CITY NAME �• INDIV 4 [DUAL LOCAL-AGENCY CORPORATION STATE-AGENCY �l PARTNERSHIP 0 COUNTY#GENCy Q FEDERAL-AGENCY U n STATE ZIP CODE 9S PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) 3(0 NAME OF OWNER SR CARE OF ADDRESS INFORMATION MAILING OR STREET ADDI�SS box bIrdk,,, CITY NpAE CJ CORPORATION PARTNERSHIP I INDIVIDUAL 0 LOCAL-AGENCY PARTNERSHIP []STATE-AGENCY CI COUNTY-AGENCY STATE ZIP CODE O FEDERAL-AGENCY PHONE#WITH AgEA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK) HQ 4 4 - o 3 1 p_ 6 •Call(916)323-9555 if questions arise. V. PETROLEUM UST FINANCIAL R ONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓OR bMbaU I SE-�-NSURED Q 2 GUARANTEEO S IETTSI OF CAECfT ED B EXEMPTION O%OTHER ID B (OTHER DE E-D A SURETY BOND NIL LEGAL NOTIFICATION AND BIUNG ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is c cked. CN ONE BOXiND/C.AInIIK:WHICH ABOVE ADDESS SHOL D BE USED FOR LEGAL NOTIFICATIONS AND BILLING: �irM> SSEENCOMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF h1YKNOWLECk3E,lSIRUE AND ICORRECTIIL APPLICANTS NAME(PRINTED a SIGNATURE) T APPLICANTS TITLE DATE MONTWDAY/YEAq LOCAL AGENCY USE ONLY COUNTY# III JURISDICTION# FACILITY# LOCATION CODE -OPT/ONAL CENSUS TRACT# -OPnONAL `^"T 05 a3aaL. SUPVISOR-DISTRICTC OPTIOA14L FORM FOFOORRRM,,MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY.