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• QATIOPOAUFORMA d STATE WATER RESOURCES CONTROL BOARD Ay W UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH LITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 RMANENTLYrIDS68,SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS p— /) NEAREST CROSS STREET PARCEL#(OPTIONAL) CIT'NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE CA odsl TO NDI RTE E3 CORPORATION ED INDIVIDUAL IJ PARTNERSHIP 0 LOCAL'AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDEMLAGENCY' If owner of UST Is a public agency,complete the following:name of Supervisor of dNkbn,eenbnDISTRICTS' ,or office which operates the UST TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.*(opdanao RESERVATION /(J// ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boxbindbaN ED INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY =CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY = 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 STflEET ADDRESS ✓box"indata I1 INDIVIDUAL LOCALAGENCY =STATE-AGENCY CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F414--]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bindicate I SELF INSURED 0 2 GUARANTEE Q 3 INSURANCE O D 0 SURETY BONG 5 LETTER OF CREDIT D a EXEMPTION m OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I Cr IGi" ed. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY K WLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED 8SIGNED) OWNER'S TITLE jFACIL1"TYi# MONTWDAY/YVR LOCAL AGENCY USE ONLY COUNTY# JU-R�RII7S-'DIIICC-�TTIIOO�N•LOCATION CODE - TION CENSUS TRACT# - L SUPVL90K-DISTRICT COD THIS FORM MUST BE ACCOMPANIED BY AT LEAS (1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWO to It /" lql�`y�� / / FOR0033AA7