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9 • ' <br /> STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD .e1ffi „a <br /> 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ED CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SGE <br /> MARK ONLY <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) FD ER OR <br /> DB RF ILITYNAME 11 Z4 <br /> EAR OSS_STflEET PMCELs(OPTIONAL) <br /> AD <br /> /— _ (,� STATE ZIP CODA <br /> Aq SITE PHONE+T WITH AREA LADE <br /> Cl NAM Ck ' CA //// // <br /> vBOX O CORPORATION D INDIVIDUAL O PARTNERSHIP DISTRICTS' O COUNTY-AGENCY' O STATE-AGENCY' a FEDERAL-AGENCY' <br /> TOINDICATE DISTRICTS' <br /> • dWkbn,sectbn,or office R owner of UST is a public agency,couplets the tdOwing:nerrw of SUPON sm of whkh operates the UST <br /> ✓ SITE E. <br /> IF INDIAN s OF TAN AT <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRU ST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA MOE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONEI WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHO <br /> WITH AREACODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME - <br /> ✓ box blydkele ED INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> =)CORPORATION O PARTNERSHIP OCOUNTY-AGENCY O FEDERAL#GENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) T�OITCORPORATION <br /> FADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ox blMktle INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY ZIP CODE PHONE a WITH AREA CODE <br /> CITY NAME <br /> IV.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 COMP TED)—IDENTIFY THE METHOD(S) USED <br /> 0 1 SELF-INSURED UARANTEE O 3 INSURANCE L I SURETY BOND <br /> ✓ bolt b Ind NdS =5 LETTEROFCREDIT 6 EXEMPTION 0 go 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.❑ it.❑ Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'S TITLE DATE MONTH/OAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION 0 FACILITY M <br /> LOCATION E - TIONAL CENSUS TRACT#-�OPTIOI�Ai�O 9UPVISOR-OLSTR TCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11) S <br /> )OR PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANKREGULATIONS FOROMAR7 <br /> FORMA(353) 0 <br />