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0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA o� <br /> � . <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION t_J 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS J' NEAREST CROSS STREET PARCEL 9(OFTIONAL) <br /> I 0 cl, �J�� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TpNDICATE 771 CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS' [� COUNTYAGENCYSTATE-AGENCY0 FEDERAL-AGENCY' <br /> Il owner of UST Is a public agency,complete the lolloWng:name of Supervisor o1 division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESER INDIIAN AN is OF TANKS AT SITE E.P.A. I.D.#(optiona)) <br /> [� 3 FARM 0 4 PROCESSOR 0 5 OTHER'I OR TRUST LANDS ,7 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonat <br /> DAYS: NAME(LAST,FIRSTt PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ✓ r <br /> MAILING OR STREET ADDRESS ` ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY E:1 STATE-AGENCY <br /> CORPORATION PARTNERSHIP []COUNTY-AGENCY 71 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> []CORPORATION PARTNERSHIP 0 CO6NTY-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)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)--IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate i SLLF-INSURLD E::]2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT E71 6 EXEMPTION 99 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.[_—] ll.[Z� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> OU <br /> �'-�� I I I I I I I I I J� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL -2, <br /> THIS FORM MUST 8E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FOR0033A-R7 <br />