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STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FOR d <br /> —1 COMPLETE THIS FORM FOR EACH F ITYIS °,t, it <br /> ❑ " <br /> MARK <br /> ONLY 1 NEW PERMIT � 3 RENEWAL PERMIT 6 C OF INFORMATION 7 PERMA TLY CLOSED SIT <br /> ONE ITEM Q 2 INTERIM PERMIT ED 4 AMENDED PERMIT CJ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ' NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TO DIICCATE CORPORATION ('INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY° FEDERAL-AGENCY' <br /> 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 0 2 DISTRIBUTOR a ✓ IF INDIAN Is OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ® 3 FARM Q 4 PROCESSOR 5 OTHER` OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE 4 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 /> NAMECARE OF ADDRESS INFORMATION <br /> i <br /> MAILING OR STREET ADDRESS ✓box b haste []INDIVIDUAL ®LOCAL-AGENCY STATE-AGENCY <br /> jV CORPORATION (_]PARTNERSHIP ®COUNTY-AGENCY (]FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK O, INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O ER - CARE OF ADDRESS INFORMATION <br /> MAILINr OR STREET A015FIESS ✓'box b indicate = INDIVIDUAL O L AL•AGENCY STATE-ACliNCY <br /> e2 1021, CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ME I STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BO OF EQUALIZATION_ UST STORAG FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ - -C <br /> V. PETROLEUM UST FiNANCIA PONSIBILITY-(MUST BE COMPLETED) IDENTIFY THE MET USED <br /> ✓box 6 =1 SELF-INSURED' Q,3 INSURANCE - Q 4 SURETY BAND <br /> 0 5 LETTER OF CREDIT Q-6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or- eked x <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: P IL BHI. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN DGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE GATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> 10-- ec . 9w Ldn r , <br /> COUNTY# JURISDICTION FACE.ITY# <br /> L ATION C TIO AL CENSUS TRACT# -OP TIO SUPYISOR-DIST CODE •OPTIONAL <br /> CA 0 <br /> THIS ORMMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SM INFORMATION 0 Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEIIENtING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM d OW) <br /> s <br />