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STATE OF CALIFORNIA .••� - �`•. STATE WATER RESOURCES CONTROL BOARD �� ' 6l 1i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA )e COMPLETE THIS FORM FOR EACH FACILITYISME MARK ONLYO NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 T�' O D SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT C::] e TEMPORARY SITE CLOSURE V I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMENAME OF OPERATOR 1f1,9h ) -0�.5�q ADDRESS I / NEAREST CROSS STREET PARCEL It(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE t WITH AREA CODE I CA S v BOX TO INDICATE Q CO AnoN Q INDIVIDUAL Q PAAT RSVP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDEMLAGENCY DISTRICTS TYPE OF BUSINESSciz 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(tWi la) RESERVATION 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS:NA (LAST,S'�R J� � �PHONE�iTH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE;WITH AREA COTIF II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Ewb Wbba Q INDIVIDUAL Q LOCAL AGENCY Q STATE44ENCY Q CORPORATION Q PARTNERSHIP Q CWNryAGENCY Q FEDERIL43ENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ` NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bwbwd:W Q INDNOUAL Q LOCALAGENCY Q STATE AGENCY Q CORPORATION Q PARTNERSMP Q COUNTYAGENCY Q FEOEMLAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 44 -L—LL�-u IJL V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Ew bYdeM Q 1 SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND 0 5 IETIEROFCREDIT Q B EXEMPTION Q 99 OTHER 71 VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 IS checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.[:] III. THIS FORM HAS BEENCOMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF AIY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# - ® 1/2 / a LOCATION CCD -OPTIONAL CENSUS:T*ATIONAL SUPVHSOR-DISTRICT CODE-OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FOROMOAd