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STATSOFCAUFORMA •`�� �'' <br /> i o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA 'r \ <br /> COMPLETE THIS FORM FOR EACHFACILITYI$ITIE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 6 GE OF INFORMATION O 7 PE LY CLOS SI <br /> ONE REM 2 INTERIM PERMIT F-14 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 4 AME OFOPERATOR <br /> a <br /> ADDRESS NEAREST CROSS STREET PARD <br /> CITY NAME At, y STATE ZIP SITE PHONE s WITH AREA CODE <br /> CA els 3� <br /> V BOX <br /> TO INDICATE O CORPORATION (] INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNtY4MNCY' STATE-AGENCY' I= FEDERAL-AGENCY' <br /> DISTRICTS' <br /> ' <br /> If owner of UST is a public agency,complete the following:nares of Supervisor ol division.ssotbn,w office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR pE- IF INDIAN s OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 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#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#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bubindlcMe O INDIVIDUAL LOCAL-AGENCY 0 STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP (]COUNTYAGENCY I=FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boxbbdb-b (] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474--]- <br /> V. <br /> 4 - L J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Oo[bMkaN I�1 SELF-INSURED L_j 2 GUARANTEE O 3 INSURANCE (]1 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION Rt 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.E-1 II.Q UL E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'STrrE DATE MONTWOAY/YE.AR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# L JURISDICTION# FACILITY III <br /> LOCATION CODE -OPCENSUS TRACTt -OP BUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BBE ACCOMPANIED BY AT ST(1)OA MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WrTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> Fgi0a711A7 <br /> FORMA(3931 <br />