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� w rc STATEOFCAUFORNIA STATE WATER RESOURCES CONTROL BOARD a4 r UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED_BITE ONE ITEM 0 2 INTERIM PERMIT CJ 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME ---Y NAME 19PERATOR� /v im_"] ,'j //� q3 _. / -i)_7 .4" ADDRESS NEARES ROS TREET PARCEL#(OPTIONAL) i`�- lf V1f YL CITY NAME STATE ZIP obm SITE PHONE#WITH AREA CODE CA ✓ BoXQ INDIVIDUAL Q PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE CORPORATION DISTRICTS' If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR 0 RESER ATIOINDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS l O v 0 D 3 C7 /m EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME"(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY (�CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE f III. TANK OWNER INFolihalfMUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADORES ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE -7 PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box IDindicate 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT O 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# t A -7 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL x. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(3193) � � FOR0033A-R7