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I I 'LeOVa - eTATEOFCAUPoRWA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLIC N-FORM A COMPLETE THIS FORM FOR EACH FACILITY W PERMIT MARK ONLY 1 NEW � 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION O 7 PEP ANENTLY CLOSED ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAMEOFOPERATOR AD ESS NEARES CRO STREET PARCELI(OPrIONAU c�a _ j ` CITY NAME -I ` VBOX C ^ ^ STACA ZIP CODE ��1 SITE PHONEe WITH AREA CODE TO INDICATE 0 CORPORATION 0/-INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' N mvner of UST lea public S; DISTRICTS' p agency,complete the lollmvin name of Supervisor d tlNlabn,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR / IF INDIAN #OFT 1 KS AT SITE E.P.A. I.D.#(apl/o]al) Q 3 FARM = 4 PROCESSOR 0 6 OTHER OORRRUST LAION EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE=TH4 DE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRSn PHONE DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS i/ a� .bl� L-1INDIVIDUAL0 LOCAL-AGENCY Q STATE-AGENCY '7 Q CORPORATION = PARTNERSHIP COUNTY AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE HONE#WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF AOGRESS INFORMATION 44/ MAILING OR STREET ADDRESS ✓borbindbam [_1 INDIVIDUAL LOCAL AGENCY =1STATE-AGENCYN� SSL DCORPORATION 0PARTNERSHIP El COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH-AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise, TY(TK) HQ 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa bin itaw 0 t SELF-INSURED L-1 2 GUARANTEE 0 3 INSURANCE 5 LETTER OF CREDIT I=] 0 W OTHER 6 EXEMPTION D 4 SURELY BOND VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[::] it.[::] IIID THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED a SIGNED) OWNER'STITLE DATE MOt4TWDAY]YEAR LOCAL AGENCY USE ONLY JIB COUNTY# JURISDICTION# .PI ��/ _FACILITY# (/ � OOv(�P ✓ LOCATION CODE TONAL CENSUS TRACT# -OPTIONAL 9UPVISOR- ISTRICT CODE - jzi. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FOAM Br UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) Fgi0033Aq7