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• • 6WR � <br /> STATE OF CAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD i c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOIt1i�mF1A('*ITYISITE MAP <br /> MARK ONLY t NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1f 2 INTERIM PERMIT u 4 AMENDED PERMIT � 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Z� t 3$75 C—V%" CC)n kap � <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME , STATE ZIP CODE SITE PHONE#WITH AREACODE <br /> —� CA QS 37(0 r�c�Ger 3iEl <br /> ✓ BOX CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL•AGENCY COUNTY•AGENCY' O STATE•AGENCY' Q FEDERAL•AGENCY' <br /> TO INDICATE DISTRICTS' <br /> 'If owner d UST Is a public agency,complete the following:name of Supervisor of division,section,or oflice which operates the UST <br /> TYPE OF BUSINESS f'pf 1 CaAS STATION 0 2 DISTRIBUTOR 0 R SERVATDION #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS ' d <br /> EMERGENCY CONTACT 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(L T, IRST) �e��fn PHONE#WITH AREA CODE I� NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> kA r <br /> PROPERTY OWNER INFORMATION«-(MUST B©E COMPLETED <br /> FNAME CARE OF ADDRESS INFORMATION <br /> I G R S ADD ESS ✓ box bindicate E::] INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> eI 5Q CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CISTATE ZIP E PHONE#WITH AREA CODE <br /> mMEC ti c usFs <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N OF OWNER CARE OF A DRE IN ORMATION <br /> rOAQC Co . 1 <br /> MAILING OR STREEJADDRESS ✓box to indicate INDIVIDUAL E�:] LOCAL-AGENCY STATE-AGENCY <br /> —� <br /> �-I ` CORPORATION : PARTNERSHIP ECOUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY` ME STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -I Q) 7 � 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDindicate 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 Il.0 III.5< <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 �ONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ELI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 ONLY. <br /> OWNER MUST FILE THIS FO BATH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR.RSTORAGE TANK REGULATIONS <br /> FORMA(3193) <br /> FOR0003A•R7 <br />