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r • STATE OFCAUPORGA �• """' STATE WATER RESOURCES CONTROL BOARD - . STORAtaE TANK PERMIT APPLICATION- A ..,. 40 CONfPLETETHE FORM FOR EACH FACiLtfYJSITE MARK ONLY ❑ 1 NEW PERMIT ❑ 9 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE" ONE ITEM ❑ S INTERIM PERMIT Q 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED) =,2rr,y"-N, NAME OF OPERATOR NEAREST CROSS STREET PARCEIopmoNAL) 6r- CITY Of STATE ZIP SITE PHONE!WITH AREA CODE CA TOIioCATE p CORPORATION p wowaK p PARTNE W;l p=M4MM p -A=WY-GFM p STATESM p F�RALAOEWY om TYPE OF WM ESS 0 t CTAS STATION Q 4 DISTRIOUTOR p IF IN DIANION OF 7770iT. .A. L D.a MpgwmO RESER p 9 FARM p 4 PROCESSOR p !i OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (MUM) EMERGENCY CONTACT PERSON (SECONDARY).optional DAYS:NAME(LAST.FIRST) PHONE i WITH AREA CODE DAYS:NAME(LAST.FIRST) NIGHTS:NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST.FIRST) 8. PROPERTY OWNER INFORMATION- UST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSbot a p WMAAL p LOCAL-AGOW p STATE-AGENCY 0 CORPORATION p PARTNERS W p COIINTY.A%NCY p FEDERALAGENCY CITY NAME STATE 21P CODE PHONE S WITH AREA CODE UL TANK OWNER INFORMATION-(MUST BE COMPLETED NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS a p MYIOINIL p LOM AGOW p STATE-AMM p CORPORAAON p PARTNERSNP p=WYAGOW p FEOERAL.AGM Cm NAME STATE ZIP CODE 7TPHONE S WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cast(916)323.9555 iI questions arise. TY(TK) HO V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED F bot b biAeta p I QED BtMRANTFF p 7 INSURANCE p 4 SURETY am p b LEM OF CREW i oXEMPRON p II OTHER VL LEGAL NOTIFICATION AND BRIM ADDRESS Legal notification and bftq will be sell to the tank owner unless box I or 11 is dwd(ed. CHECK ONE SOX KWATING WHCH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IL❑ HL❑ THIS FORM HAS BEEN CCHGIPLETED LRIDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT APPLICANTS NAME(PRINTED a SIMATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY NNn n'� JURISDICTIONa FACILrIY 33 14 ell- v -t LOCATION CODE-rT10AIAL CENSUS TRVT a- DISTRICT r -OPTIONAL 2S r Z THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. s FORM A(5-91)