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• T Ftb�R C <br /> v STATE OF CALIFORNIA r e o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> w m 1 IIp o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA , ; ;s <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F__j 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE(TEM 2 INTERIM PERMIT F] 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE H <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FbQILITY NAME NAME OF OPERATOR <br /> C <br /> ADDRESS � D K. r NEAREST CROSS)STREET PARCEL#(OPTIONAL) <br /> r Jho <br /> CITY NAME STATE ZIP CODE E PHONE#WITH AREA CODE <br /> CA -. a <br /> TO INDICATE D CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY 0 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 1 GAS STATION Q 2 DISTRIBUTOR0 RESER INDIAN <br /> #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CO ACT 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 /> II. PROPERTY OWNER INFORMATI N- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST B OMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE A OUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box b Indicate 0 1 SELF-INSURED 2 GUARANTEEINSURANCE (]4 SURETY BOND <br /> 5 LETTER OF CREDIT 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: L ED II.= 111. <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTXYML <br /> ® a 0 0 00 e Z Jea 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESSTH IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINB <br /> FORMA(3/93) FOR000314R7 <br /> LTV <br /> � iia-�� <br />