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pt60Ve : 00 <br /> STATE OF CALIFORNIA P t <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMiP <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION LV 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACT ITY AME _ / �y _ _�� NAMEOFOPERATOR <br /> ADDRESS J�CJ/�Y]xV/ ((//Nh NEAREST CROSS STREET I PARCEL#(OPrIONAD <br /> Off'!bYh <br /> CITY NAME _12_. _ STATE ZIP! I'lil a - SITE PHONEx WITH AREA CODE <br /> Y O CA [/a ///✓�' <br /> ✓ Box <br /> TO INDICATE D CORPORATION D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TS SITE E.P.A. I.D.x(opllonal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR � 5 OTHER OR A 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box ID Indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATEAGENCY <br /> CORPORATION PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP GODEPHONE#WITHAREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0lndcale O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4T41- Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box P Nloale 1 SELF-INSURED E-1 2 GUARANTEE 3 INSURANCE <br /> I�4 SUflETY BOND <br /> 5 LETTER OF COEDIT <br /> 0 6 EXEMPTION O 93 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.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> F.4elV 39 1 1 1 <br /> -OQA11UNUULIL -OPTIONAL CENSUS TRACT OPT � SUPVISO -DISTRICT CODE -OPTIONAL <br /> !�l��/i/ Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(5.91) <br /> FOR0033A 5 <br />