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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA o� <br /> � . . <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE DF WFORMATION a T P ANENTLY CLOSED <br /> ONE REM O 2 INTERIM PERMIT { AMENDED PERMIT 0 5 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) / x <br /> OFAORF TY NA.MNAME OF OPERATOR <br /> PMS <br /> ADDRESS lam, C NEAREST CROSS STREET PMCEII(OPTxNUD <br /> �C �Y si <br /> CIN NA STATE ZIP CODE SITE PHONE I WITH AREA CODE <br /> CA -EZzD <br /> Box <br /> TO INDCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY- STATE AGENLY' Q FEDEMLAGENCY' <br /> II owner of UST is a puDlit age mrrptaa the IOYowing:name al Supervsar d Civman,sett.,or of i®wheh operates Ne UST <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.Z-1 0.•(apionm/ <br /> Q RESERVATION <br /> O 3 FARM Q A PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•OP110nal <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(HST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LASf,FIRST) PHONE A TH AHEA DE NIGHTS: NAME(LAST.FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ts'm aO = INDIVIDUAL Q LOCAL AGENCY S7ATEACiNCY <br /> Q CORPORAPCN Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> Clry NAME STATE I ZIP COCE PHONE I WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADOPESS INFORMATION <br /> MAILING OR STREET ADDRESS J br nunicvl IQI INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION IQ PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE I ZIP CODE PHONE I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- -L_L_L_t. 177 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eo[uvNi�u Q I SELF-INSUPFD 0 2 GUARANTEE Q '-O' <br /> URANCE Q A SU BONG <br /> 0 5(ETTEROFCRELXT Q 6 EXEMPTION 6a 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. IL G III- <br /> THIS FORM HAS BEEN COMPL cFTED UNDER PENALTY OF PERJURY,AND TO THE BEST 1F MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHOAYNEAR <br /> LOCAL AGENCY USE ONLY {� <br /> COUNTY a JURISDICTION Y FACILITY i <br /> 0 3 v g <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> x117 7tiI2 / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS S A CHANGE OF Sn INFORIfATION,ONLY. <br /> FORM A <br /> OWNER MUST-FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS I <br /> (3'V3) FQi0m1)Al <br />