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csou" c <br /> STATE OF CAUFDF NIA <br /> STATE WATER RESOURCES CONTROL BOARD W 4U x�a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �•tooRM`' <br /> MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE ` <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSAOR ACILITY NAME NAME FOPERATOR <br /> ADDRESS NEA ST CRO REET PARCEL M(OPTIONAL) <br /> L <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CA <br /> TO INDI ATE 0 CORPORATION (]INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY F--1 COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> It 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 a t GAS STATION Q 2 DISTRIBUTOR 0 REV IF INDIAN <br /> SERVATION ><OF TANKS AT SITE E.P.A. 1.D.s(optional) <br /> 0 3 FARM Q 4 PROCESSOR rSd 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIS PHONE#WITH AREA CODE <br /> �4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WI H AREA CODE NIGHTS: N (LAST,FIRST) PHONE X WITH AR A CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMCARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR 6T4K4T ADDRESS ✓ box b Indicate INDIVIDUAL (] LOCAL-AGENCY (] STATE-AGENCY <br /> 14 O O CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITU NAME STATE ZIP ODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 5, L CORPORATION (] PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> C ji �U <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F414-1- D Z 14 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate O f SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 1�5 LETTER OF CREDIT S 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.= 11.0 III. <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY \ <br /> COUNTY# JURISDICTION# FACILITY# <br /> am <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3/93) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU JrAGE TANK REGULATKM FORMMV <br />