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o�A«� <br /> ,,;tn•. - Pte.�.... c <br /> ,.. STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W dam, o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> 06 <br /> COMPLETECOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTkc DLOSED. ITE <br /> ONE ITEM El 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ` <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DUA OR FACILITY NAME ems- NAME 0 ERATOR,' <br /> ADD SS ESTCROSS S EET PARCEL#(OPTIONAL)7X&6 ssfeAj <br /> eve <br /> CITY NAME STATE COD ,/ SITE PHONE#WITH AREA CODE <br /> krOA) CA' 061 y <br /> ✓BOX Q CORPORATION INDIVIDUAL E:j PARTNERSHIP E:] LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME-(LAST, ST)� PHONE#WITH AREA CODE D YS: NAME(LAST,FIRST) r;� � - ONE#W TH AREA CODE � <br /> y��+-TiSS: N VE�(LAST,FIRST) PH E#Ep7WlTHJ?AREA CODE NIGHTS: NAME(LAST,FIRST) If PHONE#WITH AREA CO <br /> 949W— <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> Nomf� ` CARE OF ADDRESS INFORMATION <br /> lP� i <br /> MAILING OR STREET ADDRESS ✓ box to indicate �IJIVIDUAL LOCAL-AGENCY F-I STATE-AGENCY i <br /> CZ-4rt�' -v J 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY ,g <br /> le QO <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> VA <br /> OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING IA STREET ADDRESS .` .{, /� ✓ boxto indicate 01VIDUAL LOCAL-AGENCY =STATE-AGENCY <br /> 0�?� cu& ge 'o =CORPORATION =PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME- _ STATE, ZIP CODEZ PHONE WW.1 j"' <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.= II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED SIGNATU ) TANK OWNER'S TITLE DATE MONTH>DAYNEAR <br /> LOCAL AGENCY USE ONLY , <br /> COUNTY-# JURISDICTION# FACILIT 4" <br /> m F17-1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE .`"OPTIONAL <br /> r t i <br /> THIS FORM MUST BE ACCOMPANIED BY A '° ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE S THIS IS A CHANGE,OF TION ONL . <br /> OWNER MUST FILE THIS F011TH THE LOCAL AGENCY IMPLEMENTING THE UNDERG STORAGE,TANK pEGULATI 1�5 <br /> FORM A(6-95) <br />