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STATE OF CALIFORNIA _ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION a FORK? A Cil FUP I,.a COMPLETE THIS FORM FOR EACH EACItITYISITE I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFOUIMA1I014 n 7 P G Y CLO ED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NF /9 /� NAME OF OPERATOR ADDRESS j •n NEAREST CROSS STREET I PARCEL 0(OPTIONAL) CITY NAME STATE ZIP CODE / SITE PHONE#WITH AREA CODE CA ✓ BOX TOINDICATE F__1 CORPORATION F�:]INDIVIDUAL PARERSHIP Q LOCAL-AGENCY COUNTY-AGENCY C STATE-AGENCY (�FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS U 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM C 4 PROCESSOR [_-] 5 OTHER OR TRUST LANDS u. EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME CAST,FIRST) -------PHONE-A WITI,LAREALOnF r NIGHTS: NAME(LAST,FIRST) PHONE#WI 1`11 ARTA CODE NIGHTS: NAME(LAST,FIRST) PHONE"WITH AREA C DE It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box to Indicate INDIVIDUAL [] LOCAL-AGENCY U STAT&AGENCY E�]CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY — CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE AI. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CAR[OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate I� INDIVIDUAL LOCAL-AGENCY []STATE-AGENCY CJ CORPORATION PARTNERSHIP 0 COUNTY-AGENCY [] FEDERAL-AGENCY CITY NAME _ STATE 7_IP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 14 4 — I / V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST 8 0 LETED) IDENTIFY THE METHOD(S) USED ✓ box Ioindicalo 1 SELF INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND 5 LETTEROFCREDIT 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. w CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I,❑ ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE - ,TEL MONTHIDAWY r� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Iva _ — LOCATION(AD .-OPTIONAL CENSUS TRA T --QPTIONAL SUPVISOR-DISTRICT COPE - PTIONAL THIS FORM MUST BE ACCOMPANIED trY At LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U LESS THIS IS A CHANOF SITE INFORMATION ONLY. FORM A(5-91) FCR0033A-5