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�c« STATE OFCALIFORNIA av! 1 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMITLIC TI COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY t NEW PERMIT L__1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANENTLY CLO ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION DRESS-(MUST BE'COMPLETED) DBA OR F CILITY NAME NAME OF OPE TO 6 ADDESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME / STATE ZIP97E SITE PHONE#WITH AREA CODE TO INDICATE ®CORPORATION ED INDIVIDUAL M PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' ®STATE-AGENCY' (-1 FEDERAL-AGENCY' DISTRICTS' If owner of UST Is a public agenc comps oft following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS l GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.0(optional) RESERVATION Q 3 FARM 4 PROCESSOR 'Q 5 OTHER ' OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: ME ST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRA FMONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME GARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY a CORPORATION PARTNERSHIP ®COUNTY-AGENCY F-1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 64" . -3,3 �- Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWN R CARE OF ADDRESS INF MATION MAILING OR STREETAPPRESS ✓box to indicate INDIVIDUAL ®LOCAL-AGENCY STATE-AGENCY �— =CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STAI ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY`(TK) HO FTU V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED) IDENTIFY THE OD(S) USED ✓box to Indicate 1 SELF-INSURED" [--]2 GUARANTEE -713 INSURANCE 4 SURETY BOND (�5 LETTER OF CREDIT ED 6 EXEMPTION ®99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLINGS 1.0 if.a 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY AGI COUNTY# JURISDICTION# FACL ITY# LOCATION CODE -OPTIOAIAL CENSUS TRACTS-OPTIONAL SUPVISOR-DISTRICT CODE -OP r THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATIONFORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE EGULATIDNS FORMA )