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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> FMOARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSNE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Z <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACT ITV NAME NAME OF OPERATOR <br /> �� <br /> D , 6r / A <br /> ADDRESS <br /> NEAR ST CROSS STREET PARCELi(OPrgNAU <br /> CITY NAME STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> CA �%L I ��) 77-7 <br /> TOIV BOX Nq TE 71 CORPORATION INDIVIDUAL O PARTNERSHIPLOCAL-AGENCY 0 COUNTVJAGENCY' f� STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a public agency,complete the following:narne of Supervisor d division,Notion,or office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN i OF TANKS AT SITE E.P.A. I.D.i(optional)RESERVATION I <br /> ❑ 3 FARM ❑ 4 PROCESSOR [;J�5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAM E ILAST,FIRSn PHONEa WITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME � CARE OF ADDRESS INFORMATION <br /> (� . 4. w/ I'�I —7j2b A <br /> MAILING OR STREET AD DRESS IV.0 , 0 ✓ box bIntlbate LD INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY 0 FEDERAL AGENCY <br /> � )— <br /> CIIY NAME STATE 21�DE_ PHO <br /> WITH AREA CODE <br /> '7�(7_ � r -' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN9R � I CARE OF ADDRESS INFORMATION <br /> ! CA-/, C. IC/N <br /> MAILING OR STREET ADDRESS ✓ boxbindbaN INDIVIDUAL O LOCAL AGENCY [--I STATE-AGENCY <br /> i 4 . V� C l/ /�}/� O CORPORATION PARTNERSHIP 0 COUNTYAGENCY E�l FEDERALAGENCY <br /> CIN NAME STn ZIP CODE PHONE A WITH AREA CODE <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindka�e I� I SELF INSURED E-12 GUARANTEE 3 INSURANCE O d SURETY BOND <br /> D 5 LETTEROFCREDIT O&EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USEDFOR LEGAL NOTIFICATIONS AND BILLING: L it. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME IPRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION* FACILITY It <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPIl-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SfTE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN-P STORAGE TANK REGULATIONS <br /> FORMA(353) Fgi0N7AA1 <br /> 0 <br /> 0 <br />