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'�yOVM ; CO STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA e CSI ifOXMn COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ,SZ. I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB FACILI NAME NAME OF OPERATOR D e / NEA TCROSS STREET PAflCELp(OPfIONAy CITU NAME STATE •ZIP/�T01E /i7 -� SITE PHONE#WITH AREA CODE TOO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY OCAL- G NCY l�COUNTY-AGENCY / �STATE-AGENCY l� FEDERAL-AGENCY DISTRI TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) ❑ ❑ ❑ RESERVATION Q 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) #WITH AREA COOP NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA COOP If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blMkab INDIVIDUAL LOCAL AGENCY E:l STATE-AGENCY 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY O 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 0Indkate D INDIVIDUAL 0 LOCAL AGENCY O STATE-AGENCY =CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 -L(L1LL 7L(� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED ✓ box biMicate O 1 SELF INSURED E::] GUARANTEE 3 INSURANCE 1�71 4 SURETYBOND D 5 LETTEROFCREDIT EV 6 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: I.❑ II.❑ 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAWYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# F31T 13 LOCATION CODE -OP O L CENSUS TRACT# - TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.#7; FORM A(5.91)