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STATE OF CALIFORNIA <br /> r STATE WATER RESOURCES CONTROL BOARDjaw <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIS <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /✓�j <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE OMPLETED) <br /> DBA OR FACILITY NAME , Ts� L J✓+ l ,I NAME OF OPERATOR <br /> fl RESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> h e 1 0 <br /> C�f mE ' /`. �S STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ BOX <br /> --rOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP - LOCAL-AGENCYDISTRI <br /> [�COUNTY•AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS Q .1 GASST'ATION.. }2'DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ � RESERVATION <br /> 3 FARM 4 PROCESSOR [y] 5 OTHER ORTRUST JANDS <br /> I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIT) PHONE#WITH AREA CODE DAYS: ( IME(LAST,`FTRST) n n 1 r/,I S.- <br /> Z E Ir +C PHONE it N� WITH REA Gil: <br /> NIGHTS: NAME(LAST,,FIRST) PHONEN#WI E C DE NIGHTS: NA (LAST,FIR <br /> PHONE#WITH AREA CODE__ <br /> L II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> i CARE OF ADDRESS INFORMATION <br /> NAME <br /> ,7; <br /> MAILING OR STREET ADDRESS Vbox b Indicate0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> f� <br /> (]CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 1 STATE ZIP CODE PHONE#WITH AREA CODE <br /> I <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> j MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> / X , Q CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA C DE. <br /> i <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED =2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION (] 99 OTHER <br /> i 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. II.a III. <br /> j THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> � APPLICANTS NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> /S__ <br /> w� <br /> i <br /> LOCAL AGENCY USE ONLY r 2 <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> � <br /> ; <br /> I <br /> j LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUP SO -DISTRICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONNL4- <br /> FORMA(5.91) 00` <br />