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STATE OF CALIFORNIA <br /> f <br /> STATE WATER RESOURCES CONTROL BOARD W nor r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ! NEARE TCROSSST EET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP 60DE SITE PHONE#WITH ACODE <br /> GQc� CAI/ BOX <br /> g y a <br /> TO INDICTE CORPORATION Q INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCYFEDERAL-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 O 1 GAS STATION 2 DISTRIBUTOR R SEIF 1 <br /> RVATDION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHON #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 /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING OR STREET ADDRESS ✓box b indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> p �/7 ZY ORPORATION (] PARTNERSHIP (] COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME QF OWNER CARE OF ADDRESq INF RMATION <br /> MAIL GOR STREET ADDRESStl/A-7-r A✓E'_ St,r.n ✓ box to indicate = INDIVIDUAL _ (] LOCAL-AGENCY ED STATE-AGENCY <br /> a . Q 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY F-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE _ PHONE# TH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9660 if questions arise. <br /> TY(TK) HQ F4-F4]- -1 D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxbindicats 1 SELF-INSURED F__1 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION 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: 1.0 it.0 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/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Q� III ( b <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 3UPVIS0R-DISTRICT CODE -t?P170AIAL <br /> L°j ?- 0 e-, IZt� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/93) _,�OR0033A-R7 <br /> It ��/ <br />