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• • ^teooe � co STATE OF CALIFORNIA 3 / STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA , COMPLETE THIS FORM FOR EACH WILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) `lj Z G/II9 — v — 52— 7 CITY NAME STATE ZIP CODE ITE PHONE#WI AREA CODE D4>1-7cA cD ZV'73 3 TO INBOX CORPORATION D INDIVIDUAL PARTNERSHIP LOI TRIC SENCY E-1COUNTY-AGENCYD STATE-AGENCY FEDERAL-AGENCY TYPE OF BUSINESSN 2 DISTRIBUTOR O 1 GAS STATION ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) ❑ ❑ RESERVATION 3 FARM O 4 PROCESSOR el OTHER OR TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE It WITHA ACODE DAYS: NAME(LAST,FIRST) < -� NIGHTS: N M (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAML , CARE OF ADDRESS INFORMATION MAILING OR ADDRESS S '/� ✓ box bin&ate IN DUAL I� LOCALAGENCY STATE-AGENCY O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCV CIN MME —I V STATE ZIP CODE PONE#WITH�AIRZEA COD III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION lv aMAILIN OBSTREET ADDRESS ✓ box bindicate INDIVIDUAL OLOCAL-AGENCY 0 STATE AGENCY O. ` Q O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHO ' I H CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 question arise. TY(TK) HQ 744 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate I= 1 SELF-INSURED ID 2 GUARANTEE IF1 3 INSURANCE O A SURETY BOND L-1 5 LETrEROFCREDIT =6 EXEMPTION L-1 99 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.❑ I.X III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 1 Z I P46A)10 LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 17,/17 q( Za7In-1 '520 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.FOR0033A3 FORM A(5-91) /I-