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•4a�uny 4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM Ac'/ <br /> N <br /> ��(�s4NNN <br /> COMPLETE THIS FORM FOR EACHJ46LITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ., NEAREST CROSS STREET PAHCELa(OPTIONAy <br /> CIN NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO v Box INDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL <br /> DISTRITSENCY 0 COUNTY-AGENCY [-ISTATEAGENCY <br /> STATE AGENCY D <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM O 4 PROCESSOR [:�] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) =WITHAREA <br /> DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) <br /> Pwnmr,WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biWlaN D INDIVIDUAL LOCAL AGENCY O STATE AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY-AGENCY Il FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b indicate = INDIVIDUAL D LOCAL-AGENCY D STATE-AGENCY <br /> CORPORATION E�] PARTNERSHIP D COUNTY-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 it questions arise. <br /> TY(TK) HQ F474 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx b Indicate 1 SELF-INSURED L:l 2 GUARANTEE [] B.INSURANCE 04 SURETY BOND <br /> O 5 LETTEROFCREDT I=6 EXEMPTION 9T 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY L <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CGDE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODS -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLE S THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) ogSaa A s <br /> J\-/ <br />