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w�-S�UR eg C <br /> STATE OF CALIFORNIA <br /> r STATE WATER RESOURCES CONTROL BOARD a_. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICA N- FORMA �a <br /> a n <br /> u o 'tirf q O <br /> COMPLETE THIS FORM FOR EA H FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 ER ENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME r NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> A36-C) W <br /> CITY NAME STA ZIP CODE SITE PHONE#WI AREA CODE <br /> ✓ BOX <br /> TOINDCATE CI CORPORATkON NDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY [ ]COUNTY-AGENCY ® STATE-AGENCY [ FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR � ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 16 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME('JrAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) q7 f <br /> PHONE IVITIA AREA Q <br /> NIGHTS' <br /> NAME(LAST,FIRST) <br /> PHONE# ITH AREA}CODE _ NIGHTS:�NAJ�ME/(LAST,FIRST) f1 r � <br /> !'1 u V{ �C 'V !'r"Z � ! PHONE 40 ITH AREA COOr <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME a CARE OF ADDRESS INFORMATION. <br /> MAILING OR STREET ADDRESS ✓ bow windbate NR1DIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP ® COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER t c 4 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 indicate INDIVIDUALLOCAL-AGENCYSTATE-AGENCY <br /> (] <br /> j__� — CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE)) PHONE#WITH AREA CODE <br /> !1� E <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(918)323-9555 if questions arise. <br /> TY(TK) HQ �4"I 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> box loodicale 1 SELF-INSURED C 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION [7 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless box I or lI is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I, — II.❑ III. <br /> TH)S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNLAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL StIPVISOR-DISTRICT CODE - PTICNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR M(/OGRE PERMIT APPLICATION- FORM B©, CUNLESS THIS IS A CHANGE OF SITE IN . RMATION ONLY. <br /> FORM A(12 91} FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS " <br /> FOR0033A-R6 <br /> Ac <br />