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'tOOVR X - Oo STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD w� , DERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ` 3 OXXX COMPLETE THIS FORM FOR EACH FA (SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR L ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 2 2L/ S. S� CITYNAME STATE ZIP CODE SITE PHONE#WITH AREA CODE L/c CA v BOX TO INDCATE -1 CORPORATION E-1 INDIVIDUAL PARTNERSHIP 0 DISTRICTS ENCY D COUNTY STATE AGENCY D FEDERAL-AGENCY TYPE OF BUSINESS O 1 GAS STATION '❑ 2 DISTRIBUTOR ❑ RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) O 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) DuQklc a WITH AREA GOOF NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / / ��y"� ✓ box bintlkaN O INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY 2 -717 /h vL(�`P ✓ " 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindkata O INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY =CORPORATION O PARTNERSHIP O COUNTY-AGENCY = FEDERAL AGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. TY(TK) HQ [4X-- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box b Indicate 1 SELF INSURED O 2 GUARANTEE O ] INSURANCE O 4 SURETYBONO 5 IETTEROFCREDIT =6 EXEMPTION 0 W OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is chGCked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACIL�ITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CADS -OPTIONAL OS�1V. 3 a3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANII OF SRE FORMATION ONLY. FORM A(Set) FOBW9aA5