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STATE OF CAUFORNIA -r STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- A COMPLETE THIS FORM FOR EACH FACILRYISITE aC"'� • �.,,,a„�'� D MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION X7 PERMANENTLY CLO SED SITE ONE REM 2 INTERIM PERMIT Q X AMENDED PERMIT a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBAOR FACILITY NAME ?/�,1 l G I✓IV P1 t `ctEOF OPERATOR ADDRESS NEAREST CROSS STRE PARCEL#(OPTKNML) �CfTY tT"EDE SITE PHONEa WITH AREA CODE I/ Box `1 TO DICATE D CORPORATION O INDIVIDUAL (]PARTNERSHIP LCI LOCAL-AGENCY O W TGENCY O COUNTYAGENCY' O STATE-AGENCY• O FEDERALAGiENCY' -ff owner d UST k a pubic perry,aonplele the idNnAnB:name d Supervisor of alvkbn,a ion,or office which operates the UST TYPEOFSUSINESS Q 1 GASSTATION Q 2 DISTRIBUTOR / IF INDIAN 18 OF TANKS AT SITE E.P.A. I.0.a(comnal/ 4111 Q 3 FARM Q ♦pgOCESSOR 5 OTHER ORESERVATION R TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) aPHOINE i WITH A9EA� y ' DAY3: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: LAST.FIRST) PHO a WITH AREA CODE A NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE �f II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bb9cds INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY CORPORATION Q PARTNERSHIP CDUNTY-AGENCY FEDERALAGENCY 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 ✓ in to militate INDIVIDUAL (]LOCAL AGENCY srATE-AGENCY O CORPORATION Q PARTNERSHIP Q COUNTYAGENCY E-3 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HO 4 4 -�+�-F I V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓00a blMkale 0 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O s SURETY BOND 5 LETTER OF CREDIT Q a EXEMPTION O N 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 BILLING: I. 11.= M.E] THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED B SIGNED) OWNER9 TITLE DATE MONTHIDAYNEAR 3 LOCAL AGENCY USE ONLY ) COUNTY Y JURISDICTION Y FACILITY* LOCATION CODE -OPTIONAL CENSUSTRACTa-OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL J11 THIS FORM MUST BE ACCOMPANIED BY A LAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE 0FORMATION ONL \ \ OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIS FORM A(MU) - FORpp U-M