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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W �° "1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �s . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED,SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 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 /> S -N .S <br /> ADDRESS NEAREST CROSS STREET PARCEL#(0 ONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX ]CORPORATION ]INDIVIDUAL ] PARTNERSHIP LOCAL-AGENCY ]COUNTY-AGENCY' ] STATE-AGENCY' ] FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> ff 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 BUSINES 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR ] 5 OTHER OR TRUST LANDS g' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PH ON #WITH AREA CODE <br /> A'V <br /> �7 <br /> NIGHTS AME(LAST,F ST) ©0 ATH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#W" REA CODE—r <br /> , 4d11 <br /> II. PROPERTY 0 NER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN OR STREET ACD—ftrss box to indicate ] INDIVIDUAL ] LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP ]COUNTY-AGENCY ] FEDERAL-AGENCY <br /> CITY NAME „r. STATE ZIP CODE PHONE#WITH AREA CODE <br /> So a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate ] INDIVIDUAL ] LOCAL-AGENCY ] STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ <br /> F4T4-10111 <br /> - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 10 indicate 1 SELF-INSURED ] 2 GUARANTEE ]3 INSURANCE I]4 SURETY BOND ] 5 LETTER OF CREDIT ]6 EXEMPTION =7 STATE FUND <br /> D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER ]9 STATE FUND&CERTIFICATE OF DEPOSIT ] 10 LOCAL GOVT.MECHANISM ] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[--] it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHJDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> all l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPT ONAL <br /> 1 8: <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 <br /> TH THE LOCAL AGENCY IMPLEMENTING THE UNOERGROU STORAGE TANK REGULATIONS <br /> A FORMA(6-95) QQ �A� <br /> iP� <br />