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STATEOFCAUFORMA • ,V'1ij c�o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM Ap,- COMPLETE THIS FORM FOR EACH FACILITYISTTE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE ✓j^l//) I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) [RA OR ITV AME NAMEOF PE TOR OR S ISCOSSSTREETPMCELN(OPTIONAU Y NA E STATE ZI ODE.. )� SITE PHONE N WITH AREA CODE CA '/ BOX CD CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY' 0 STATE-AGBNCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS' If owner d UST Is a pubOc agency,mnpldm e the following:name of Supervisor of division,section.or oNim which cperstae the UST TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN NOF TANKS ATSITE E.P.A. I.D.s topfirnall ❑ ❑ RESERVATION Q 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER ORTRUSTLANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREACODE 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓box blndhale M INDIVIDUAL ED LOCAL-AGENCY M STATE-AGENCY Q CORPORATION [::] PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE III. TANK OWNER I FORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindaale 0 INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY []CORPORATION O PARTNERSHIP O COUNTYAGENCY [--I FEDERAL-AGENCY CITU NAME STATE ZIP CODE PHONE N 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 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPI D)—IDENTIFY THE METHOD(S) USED = t SELF-INSURED 2 ARANTEE 03 INSURANCE 1�4 SURELY BOND ✓ box blMkaN O 5 LETTER OF CREDIT 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 checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IL[:] ILL THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTHIDAVNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION x FACILITY# 9UPVISOR-DI9 IC�� /I LOCATION CODE - L CENSUS TRACTS. - TIQNAL O THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNL SS THIS 1S A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR�MR FORM A(393)