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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> MARK ONLY 0 <br /> < <br /> , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ Y�1 NEW PERMIT ' <br /> ONE REM ❑ S RENEWAL PERMIT ��ronx•^ <br /> ❑ 2 INTERIM PERMIT p 5 CHANGE OF <br /> < INFORMATION <br /> I. FACILII Tiol It INFORMATION&ADDRESSS ENDED PERMIT ❑ 7 PEflMANENTLY CLOSED SITE <br /> ❑ 8 TEMPORARY SITE CLOSURE <br /> DBA OR FACILITY NAME ` (MUST BE COMPLETED) <br /> ADDRESS _ S NAMEOFOPERATOR — <br /> NEARESTC O ) � <br /> CITY NAME SS STRE 7 <br /> ' � P EU(OPrpNAL) <br /> 1-'� 97�A 21P CODE _ <br /> TO NDI RTE 0 CORPORATIONINDIVIDUAL 0 PARTNER <br /> SHIP <br /> •II owner d UST Is a public agency,mnplele the to) SHIP <br /> 0 LOCALAGENCY - <br /> TYPEOFBUSINESS g:pame olSupervbor of drvbbn,seclbn�Srury�wwpkh DCOUNTY-AGENCY• 0 ATE-AGENC <br /> ❑ 1 GAS STATION ❑ 2DISTRIBUTOR °Pante.the UST OFEDERAL#GENCY' <br /> ❑ S FARM ❑ 4 PROCESSOR O ✓ IF INDIAN <br /> 5' OTHER IF <br /> •OF TANKS A7 SITE E.P,A I.D.. <br /> OR TRUST LANDS Ieemonal/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) Y <br /> DAYS: NAME(LAST,FIRST) ' <br /> > <br /> PHONE*WITH AREA CODEPHONE#WITH AREEMERGENCY CONTACT PERSON (SECONDARY). <br /> 'K DAYS: NAME(LAST,FIRST) bAREA <br /> S: NC <br /> NIGHi (LAST FIR T) � A CODE <br /> ONE• H q <br /> I DE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- PHONE a WITH AREA CODE <br /> NAME MUST BE COMPLETED <br /> MAILING OR STREADORE CARE OF ADDRESS INFORMATION <br /> E � <br /> ✓ <br /> CITU NAME box to irgkyq <br /> O CORPORATION INDIVIDUAL DLOCAL-AGENCY <br /> O PARTNERSHIP D COUMKAGENCY STATE AGENCY <br /> `� STATE ZIP CODE DFEDERAL-AGENCY <br /> III. TANK OWNEANFORMATION-(MUST BE COMPLETED) ` ` PHONEN WITH AREA CODE <br /> NAME OF OWNER <br /> MAILING OR STREEAD" CARE OF ADDRESS INFORMATION <br /> T ESS �? <br /> U ✓box birAicale <br /> CITU NAME O <br /> O CORPORATION INDIVIDUAL 0 LOCAL AGENCY O STATE-AGENCY <br /> 0 PARTNERSHIP 0 COUNry• <br /> STATE ZIP CODE AGENCY 0 FEDERAL AGENCY <br /> PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91 6)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ ba biiJcye 1SELF-INSURED 0 2 GUARANTEE <br /> 5 LETTER OF CgEDIT 0 3 INSURANCE <br /> CJ 6 EXEMPTION 0 W OTHER O 4 SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxor Il llor is IIs checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PEq•/URY•AND TO THE BEST OF I II.❑ III ❑ <br /> OWNER'S NAME(PRINTED 8 SIGNED) MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# l%i i4I _ __- <br /> JURISDIC ION It -' _ <br /> IT-1 FACILITY# <br /> LOCATION CODE -OPTIONAL• CENSUS TRACT# .OPTIONAL r `� ( � ig <br /> 9111 11ISOp-11IS5 511 COOE -CPTAONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MDgE PERMIT APPLICATION• _I 'f INFORMATION <br /> FORM A(399) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING TOE UNDERGROUND D STOR GSS THE 18 AEITANGK REGULATKINS 0 Y. <br /> 0 D a l X11 5(F 1 � <br /> s-kV �"i �. kio <br />