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• 'troun f C STATE OF CALIFORNIA --'- STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA 4 a: COMPLETE THIS FORM FOR EACH FACILITY/SITE oa MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 5, NAMEILITY NAME CNAME OF OPER TOR 2j -`7p''',, D NEARES CROSSSTREET PARCELCOPTIONAL)STATE ZIP CODESITE PHONE#WITH AREA CODEC4E CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCYT is a public agency,complete the following:name of Supervisor of div s on,sect onDor otflce wh ch C] COUNTY-AGENCY' TATE-AGENCY' = FEDERAL-AGENCY' INESS operates the UST ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.# 3 FARM 2 RESERVATION (optional) 0 4 PROCESSOR LLJJ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: N (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) O PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME A CARE OF ADDRESS INFORMATION MAILING UH S-•1 REET ADDRESS ;^t J ✓ box b Indicate [] INDIVIDUAL (] LOCAL-AGENCY V 0 CORPORATION STATE-AGENCY CI NAME O PARTNERSHIP E COUNTY-AGENCY 0 FEDERAL-AGENCY C _ , [ STATE ZIP CODE PHONE#WITH AREA CODE c 0 C.tc�/U G�-- 9 Is— III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 0 CORPORATION CITY NAME C� PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ [4_[4_-]- V. 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box ID indicate 0 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 4 SURETY BOND 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 9hecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I•❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MON"], DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# /h /Q i FACILfTY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP7ADNAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY- FORMA(3r93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM • FOR0033A-R7