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• • eeooa e c c ^ STATE OF CALIFORNIA w STATE WATER RESOURCES CONTROL BOARD NDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �f�lf Oe N.e J COMPLETETHIS FORM FOR EA9 RYISITE MARKONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SE SITE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERATOR DBA OR FA ILIT—/V/NAME �I� � 1-CLS /9L NEAREST CROSS,STREET PARCEL#(OPTIONAq ADDRESS �f 3loVL �') CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA LADE CA 01 S_? ✓ Box TOINMCATE O CORPORATION ED INDIVIDUAL O PARTNERSHIP DISTRICTS LOCAL-AGENCY 0 COUNTY AGENCY QSTATE-AGENCY 0 FEDERAL-AGENCY ❑ I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Wfional) TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST,FIRST) II, PROPERTY OWNERINFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓ box bindbale INDIVIDUAL LOCAL-AGENCY O TATE-AGENCY 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY Q FEDEMLAGENCY CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxbindbale � INDIVIDUAL 0 LOCAL-AGENCY O STATEAGENCY 0 CORPORATION = PARTNERSHIP 11 COUNTY-AGENCY l� FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF QUALIZATION LIST STORAGE FEE AC UNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 O O V. PETROLEUM US SIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMicale I SELF-INSURED F�2 GUARANTEE11 S INSURANCE O 4 SURETY BOND O 5 LETTER OFCREDn =6 EXEMPTION 0 %OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I I is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTEDB SIGNATURE) APPLICANTS TITLE 77 MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY �IL� y3 9 LOCATION CODE OPTIONAL CENSUS TRACT# - OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONA!^^ (C�, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFOR TION FOR0037A 5 FORMA(5-91)