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- • � � e60VR !' <br /> F �vu C <br /> STATE OFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD W xn�' Jena <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY)SITE °�tifonN <br /> MARK ONLYt NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL <br /> ONE REM LY 2 INTERIM PERMIT E:] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA Q CILITY NAIVIE NAME S <br /> a i C_ . <br /> ADORES `4-e z; NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP SI PH #W AREA OE <br /> atm . CA <br /> BOMom <br /> x <br /> TO INDICATE [12rORPORATION Q INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY DISTRICTS' W77000UNTY-A"C"ENCY. STATE-AGENCY' 0 FEDERAL-AGENCY <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 GAS STATION 2 DISTRIBUTOR RESERVATION <br /> FINAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> nALVQ- m- DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> N CARE OF ADDRESS INFORMATION <br /> ✓box bindicate 0 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAM STATE 'PIN <br /> IP DQDE,,, ` , P ONE#��TIH AR A CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �b(5L6L <br /> NAI 9F NER CARE OF ADDRESS INFORMATION <br /> eir <br /> MA NG OR ST^Rf ETT ADDRESS ✓box bindicate INDIVIDUAL LOCAL-AGENCY = STATE-AGENCY <br /> CORPORATION PARTNERSHIP (]COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N ,p, ST�� ZIP J� �� PHONE W H AREA CODE,7?// <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. 7 6 L <br /> TY(TK) HQ4 _ - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b indicate 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE (]4 SURETY BOND <br /> 5 LETTER OF CREDIT (�6 EXEMPTION 99 OTHERill 0 <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: I.❑ 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 EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 12111 ( <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z f Zq Ill <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM W� <br /> FORMA(3/93) �THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ORALE TANK REGULATKNIS <br /> FOR0033A4i7 <br />