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47y q <br /> R <br /> �y. C <br /> STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE 4"I.artN'` <br /> MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E�] 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE 0j/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY AME ) J NAME OF OPERATOR <br /> ADDAESP NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP COQE <br /> ITE PHONE#WITH AREA CODE <br /> CA <br /> I Box <br /> T NDIC TE CORPORATION 0 INDIVIDUAL [�PARTNERSHIP DISTRICTS' <br /> COUNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAL-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 O 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTA T PERSON (SECONDARY)-optional <br /> DAYS: NAM (LAST,FIRST) PHIONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PVONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1177- <br /> 11. <br /> 177—II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> C/Y,N STATE ZIP CODE '1 PHONE#WITH AREA CODE y <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OOWr NFA CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ./ box b indicate INDIVIDUAL ED LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> k. CI ro STA ZIPDE - ONE#WITH AREACODS <br /> t Z�' J � � ? <br /> f IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F414-1-1014-W16 6 <br /> E <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br />�'' ✓ box b indicate i 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> f D 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> I <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: <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 /> l <br /> i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �,-- <br /> 1 111, ? 10 ,/. <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 /> FORMA(3193) <br /> OWNER MUST FILE THM FOAM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND RAGE TANK REGULATM <br /> FOR0033A-R7 <br />