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• • t` J- C STATE OF CALIFORNIA :` sr STATE WATER RESOURCES CONTROL BOARD i., „b UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA .� , os COMPLETE THIS FORM FOR EACH FACILRYISITIE `'x�.eae�' MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE ONE REM ❑ a INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D OR ACILITVN E , NA OFOPE TO 1 a M �� ADDRESS I NE ST—CRCISS STREET PARCEL a(OPTIONAQ or CIW NAME STATE ZIP �_3 SI PHICN 4 ITH R CODE TOINDI RTE CORPORATION I� INDIVIDUAL I� PARTNERSNIP p�TnICTSZCY O COUNTY-AGENCY' O STATEAGENCY' 0 FEDEMLAGENCY' If owner of UST Is a public agency,complete the following:name of Supervisor of div Z. section,or office which operates the UST TYPE OF BUSINESS ❑ t GAS STATION 2 DISTRIBUTOR ❑ RES/ IF INDIAN ERVATION a OF TD AT SITE E.P.A. I.D.a(apHanaQ 0 3 FARM 0 4 PROCESSOR 6 OTHER ORTRUSTLANOS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONEe WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box b Indicate Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY O CORPORATION O PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE 1777 HONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - Q Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED ✓ box blndicab I SELF INSURED 2 ARANTEE 3INSURANCE O 4 SURETY BOND D 5 LMEROFCREDIT EXEMPTION 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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ I.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION p FACILITY r 3 P� lzql I � LOCATION CO ?- TONAL CENSrTgA Ta! J1B(VAL SUPVISOR-0 T T -� NAL /l/1 G/ /�' (✓ L— THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG FORM A(3/93) G FOR0m3Afl7 . 0