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STATE OF CAUFORMA <br /> OTE WATER RESOURCES CONTROL BOARD i•WP+J, -'� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATIO - ORS. 'A <br /> COMPLETE THIS FORM FOR EACH FA rTY'SfTE <br /> NARK ONLY L._ 1 PERMIT j 7 RENEWAL PERMIT r CHANGE OF INFORMATION J 7 PERMANENTLY CL q <br /> GHE ITEM 2 -RIM PERMIT A AMENDED PERMIT 1 a TEMPORARY SITE CLOSURE D [/ <br /> L FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE OMPL ) <br /> CdA CB FAC W N NAME AME OF OPERATOR <br /> aCCRESS NE ARESTCRCSSSTREET PARCELIICPTIONAU <br /> C:N.Va`.iE STATECA ZIPISITE PHN—WI HAREA ODE <br /> ✓ PDX .Q CORPORA➢ON Q INDIVIDUAL PARTNEASWP Q LOCAL-AGENCY Q COUNrY AGENCY D(� <br /> TOINCICATE _ Q STATE Q,I FEDERAL AGENLY <br /> DISTRICTS <br /> TYPE OF 3USINE55 I GAS STATION j 2 DISTRIBUTOR Cj ✓ �F INDIAN s OF TANKS AT SITE E.P.A. L 0.a(=,,WWI <br /> 1 RESERVATION <br /> 7 FARM Qi a PROCESSOR a 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlanal <br /> JAYS: NAME(LAST,FIRST) PHONE q WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 NTH AREA r0,nP <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> I-ClIc I pPTI.I qqc A"nc <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING CR STREET ADDRESS ✓ m,0m INONIOUAL <br /> Q Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PMTNERSWP Q COUNTYAGE.NCY Q FEDERAL.AGENCY <br /> CIN.vaNIE STATE ZIP CODE PHONE a WITH AREA CCCE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ]OgbNtlY:L1 <br /> IQ INOIVOUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHP Q COUNTYAGENCY Q I'MERALAGENCY <br /> CITY NAME STATE I ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323.9555 if questions arise. <br /> TY(TK) H074 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED <br /> ✓ py erlgt>tA Q I SELF-INSUREO IQ t GUARANTEE Q 5 NSURANCE Q A SURETY ECNp <br /> 0 5 LETTERDFCRELYT Q 9 EXEMPTION Q 99 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 WLLING: I.= IL= IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPL.CANT'S NAME(PRINTED B SIGNATURET APPLICANTS TITLE DATE MGNTWOAY/YEAR <br /> z:7-3a z <br /> LOCAL AGENCY USE ONLY w <br /> COUNTY x JURISDICTION x FACILITY a <br /> 5 � a <br /> LOCATION E -OPTIONAL CENSUS TRACT 9 -OPTIONAL SUPVISOR•DISTRICT E -OPTIONAL <br /> Z <br /> THIS FORM MUST B ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• ORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5911 FCR=3A.S <br />