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i <br /> N <br /> STATE OF CAUPORMA <br /> r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F__] 5 CHANGE OF INFORMATION Q 7 PERMANENTLY SED IT <br /> ONE REM 2 INTERIM PERMIT 71 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI)�" NAME OF ORERATOR J <br /> ADDRESS / NEAR O STR IET PARCEL N(OPTIONAL) <br /> CITY NAME6, - STATE A ZIP C SITF_PHONE s WI AREA CODE- <br /> 3�/ <br /> I/ Box <br /> TO INDICATE CORPORATIONNDIVIDUAL (]PARTNERSHIP O LOCAL-AGENCY <br /> OCAL-3 CY COUNTY-AGENCY' I]STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> I <br /> If owner of UST is a public a ncy,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS Ey 1 GAS STATION 0 2 DISTRIBUTORRESERVATION IF INDIAN #OF TAN S AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS � <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) 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 /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G M LI STRE DRESSKAA ✓ box bltMkate 0 INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> « CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYN E STATE ZIP CODE� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE _T 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- - 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate = i SELF-INSURED 2 GUARANTEE El NSURANCE, 4 SUREE BOND <br /> =5 LETTER OF CREDIT (]6 EXEMPTION U99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EV II.E 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY L� <br /> COUNTY# JURISD�ICTIOON# FACILffY 4.14A <br /> 3 `�Ij' j <br /> LOCATION CO OPTIONAL CENSUS TRACT# -10F}TI L 75Py�IsTR T OP 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE iWORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM �U <br /> FORM A(3/93) FOROMM4 7 <br />