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C6pUn � P .vn.• � STATE OFCAUFORWA STATE WATER RESOURCES CONTROL BOARD W m UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA �c , COMPLETE THIS FORM FOR EACH FACILITYISRE MARK ONLY D t NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHO4NE#WITH AREA CODE �!®%J/ CA Z�) } —/ TOINDIICO TE ED CORPORATION F-1 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY (]STATE-AGENCY (] FEDERAL-AGENCY' 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 t GAS STATION Q 2 DISTRIBUTOR 0 REV IFSERINDIAN #OF TANK AT SITE E.P.A. I.D.#(optional) 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OITRUSTLANDS 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 If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME,/ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY C'C ^ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY t CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE I '-'Y) sf IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bIndicate (] 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE (]4 SURETY BOND O 5 LETTER OF CREDIT 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: I.D if.[:] 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 8 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 7 " FFFI 1,1,13 1 f 3 `Wz9�� LOCATION CQDE -OPTIONAL CENSUS TtlAQT#•OPTIONAL SP2 of I UPVISOR-DISTRICT CODE -OPTIONAL I ? �5 // ?j/.l 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(3/93) FOR0033A•R7 b 0