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• 0 w" yyyl <br /> STATE OF CAUFOFMA e <br /> iy 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. 'FACiLITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R Cl I�®AME, JiX�n NAMED OPERATORADOR rnV� NEA CSF S REST PARCEL PTK7NALJ <br /> 11'�p1r/ � <br /> CITY NAME STATE ZIP CO SI PH E# IT AREA COD <br /> CAZZ� . <br /> I/ BOX © COUNTY-AGENCYFEDERAL-AGENCY' <br /> TO CORPORATION INDIVIDUAL ]PARTNERSHIP DISTRICTS, <br /> ' <br /> II owner of UST Is a public agency,complete the following:name o1 Sipervisor of d1vIsion,sec4'wn,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ] 2 DISTRIBUTOR Q ✓ 4F INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM d PROCESSOR [�j 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT 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 INFORMATION- MUST BE COMPLETED <br /> NAM �, CA OF AD v)��0 INFORMATION hh�ez, <br /> MA O STRCk-(� 5 _ / box toInakate [] IN9IYIDUAL (� LOCAL-AGEN Y 0 STATE-AGENCY <br /> ' n s� 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CI N , kk✓✓✓ STIy _ ZIP CODE Y HONE#WITH AREA CODE <br /> 11 reA- !fir'!11 fr/J(/f6 f7i 0 <br /> LNAME <br /> K OWNER INFORMATION•(MUST BE COMPLETED) <br /> WNERCARE OF ADDRESS INFORMATION <br /> STREET ADDRESS . bop ioindicats ] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP l]COUNTY-AGENCY [ FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1V.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDindkate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q4.-SURETY BOND <br /> Ci 5 LETTEROFCREDIT D 6 EXEMPTION D %OTHER !� <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unies ',box I or II i hocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.4 <br /> II. II. <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRJE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE \ MONTHIDAYNEAR <br /> -1f <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY 0 ! <br /> 59 1 1 1 1 ?R11311 P I Rd �4 <br /> LOCATIOU OE -OPTIONAL GENSUS TRACT r -OP L A SUPVISOR•DISECCQDE; -OP MAL <br /> UT <br /> 1 0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMrf APPLICATION- FORM B,UNLESS THIS 113 A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK'REGULATUM <br /> FORMA(3/93) <br /> FORars3A-Rt <br />