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• y-80VnC� STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C'� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EA FACILRYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J DBA OR FACILITY NAME NAME OF OPERATOR r 7AQ ADDRESS NEAREST CROSS STREET PARCEL p(OPFIONAL) CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE ✓ BOX CA TO INDICATE D CORPORATIONDIVIDUAL O PARTNERSHIP E�] L AL-AGENCY COUNrYAGENCY D STATE-AGENCY E:l FEDERAL-AGENCY TflICTS TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal)RESERVATION O 3 FARM O 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME LAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NA WITH AREA COOP IGHTS: N M (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COnF Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION uF C'4u vt �c r MAILING OR STREET ADDRESS ✓ INDIVIDUAL box to D 1/ � LOCAL-AGENCY Q STATE-AGENCY J 9 �� Nl U / ORPORATION PARTNERSHIP COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME ��G` R rrid STATE ZIP CODE PHONE#WITH AREA CODE cilifo-11Y3 73 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box 0Indicate INDIVIDUAL LOCAL-AGENCY INSTATE-AGENCY =CORPORATION D PARTNERSHIP E-1 COUNTY AGENCY 0 FEDERAL-AGENCY CITY 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 F4-[4]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box 0 indicate I1 1 SELF-INSURED =2 GUARANTEE Q 7 INSURANCE D 4 SURE Y BOND D 5 LETTER OF CREOT = 8 EXEMPTION 0 99 OTHER VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ I. I.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO WLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY Ce 70 LOCATION CODE -OPTIONALCENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 0 z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FO(i0V�7_ AS