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• �G STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • 10MA A COMPLETE THIS FORM FOR EACH FACILTTYISITE 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 53 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA 'CILITYf�;A . I 1 NAME OF OPERATOR ADDR E�,Cp/ NEAREST CROSS STREET PARCEL#(OPIONAq Q Morn 4M d CITY NAME STATEZIP / SITE PHONE#WITH AREA CODE CK f_" cAU TOIN Box O CORPORATION I3 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY ISTRICSl3 COUNTY-AGENCY O STATE AGENCY FEDERAL-AGENCY TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION #OF TAkN NKT SITE E.P.A. I.D.#(aptimap Q 3 FARM a 4 PROCESSOR Q 5 OTHER OR TflUST LANDS /l//`/� EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) a WITH APPA rnnp NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE II• PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ mxmm % Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY O CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY CITY 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 ✓ lax mmtala Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY AGENCY D FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 0 3 2 2 2 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wx 0 Wicap SELF-INSURED 2 GUARANTEE 0 3 INSURANCE [___1 4 SURETY POND V-5 LETTERCFCREOIT D e EXEMPTION O 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.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAM E(PH INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR I LOCAL AGENCY USE ONLY COUNTY# r JURISDICTION# FACILITY# ® SE ev 9/ QI I 1 1 / 18 8 a 18 q LOCATION COD�57TIONAC CENSUS TP, ; WIYONAC SUPVISOFZ-DISTRICT CODE -OPTIONAL 00 3�tl THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(591) fOR00.i1A5