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• '`g uq x <br /> STATEOFCAUFORNIA �� t' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT PLICATION- FORMA '�� b <br /> COMPLETE THIS FORM FOREAC ACILITY/SITE C'lV0^"". <br /> MARK ONLY t NEW PERMIT r7 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT E:] 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME A E OF OPERATOR <br /> ADDRESS D N REST CROSS STREET PARCELS(OPTIONAL) <br /> CITY NAME ° STATE ZIP SITE PHONE S WITH AREA CODE <br /> 1 CA <br /> TO/ BOXTE D CORPORATION INDIVIDUAL D PARTN HIP LOCAL-AGENCY COUNrY-AGENCY• O STATE-AGENCY' EDFEDERALAGENCY' <br /> DISTRICTS' <br /> It owner of UST Is a public agency,complete the following:name of Supervisor of divkbn,section,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR gESE11 <br /> RVNDIAN a OF TANKS SITEI E.P.A. 1.D.a(opfbnal) <br /> ATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b limbaM O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindiAW O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> (�CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F41-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box bink" O i SFLF INSURED [::]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION O go 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: U= 11.[=] 111.O <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(PRINTEDB SIGNED) OWNER'S TITLE DATE MONTRIDAYNEAR <br /> ✓ti - 93 <br /> LOCAL AGENCY USE ONLY W� <br /> COUNTY 2 JURISDICTION FACILITYA <br /> 11� <br /> LOCATIONCOD02�OPT CEN S T CT •D�TIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> 414 <br /> THIS FORM MUST E ACCOMPANIED BY Af LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) �j FORW77AAT <br />