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s�uee¢s <br /> STATE OF CALIFOANIA " <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA � '. �° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY1 NEW PERMIT F7 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM INTERIM PERMIT 4 AMENDEO PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> pDA CILITY AME NAME OF PFRATQR /►�� S�-^ <br /> ADD NE ST CROSS STREET PARCEL a(OPTIONAL) <br /> 1, �5(�to or r <br /> CITYM STATE ZIP SITE P ONE WI ARFA CODE <br /> x"1..41 CA yT <br /> TO DIATE F71 CORPORATION O INDIVIDUAL PARTNERSHIP F7 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR 0 R I/ IF IN <br /> SERVATDIAN "OF Tjb.AAT.SITF E.P.A. I.D.$1(optional) <br /> O 3 FARM 4 PROCESSOR a 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONF a WITH ARFALO <br /> NIGHTS: NAME(LAST,FIRST} PHONE b WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II, PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ./ box IDind'cate (] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION I] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MU$T BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP OCOUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE>!WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 1414 `-F0 1p Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boy to indicate 1 SELF-INSURED0 GUARANTEE C] 3 INSURANCE LL 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION D9 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 WFI CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.L] II.n IL <br /> T"IS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTH/DAYIYEAR <br /> T <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION it FACILITY# <br /> =yo - <br /> LO1ATIONy//L`1 -OPTIONAL CFNSUS TRAA�T# -0 NAS SUPVISOR-D STRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR[MMOORE PERMIT APPLICATION• FORB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> F ORM A(,2-s1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F0110033A-116 <br />