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STATE OF CAUFOBWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D 1 NEW PERWT 3 RENEWAL PERMIT LJ 5 CHANGE OF INFORMATION [7] 7 PERMANENTLY CLOSESl7.E... _ <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT & TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ' NAME OF OPERATQR ` <br /> I ti ! (" IySL1J i3o t <br /> '1 r <br /> ADDRESS f NEAREST CROSS TRIVET PARCEL N(OPTIONAL) <br /> UIYI IIL STATE ZF_9OID } SITE PHONE WITH AREA CODE <br /> tl f j — ' CA "rJI 6 <br /> TO INDICATE CORPORATION F1 INDIVIDUAL PARTNERSHIP E::] LOCAL-AGENCY COUNTY-AGENCY' ®STATE-AGENCY' [] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> II owner of UST Is a public agency,oornplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN x OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRiJST LANDS J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 ✓ box to indicate INDIVIDUAL E-1 LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> =CORPORATION PARTNERSHIP 0 COUNTY-AGENCY © FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA COOT <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate I SELF-INSURED [ 2 GUARANTEE [--11,3 INSURANCE C] 4 SURETY BONO <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION I 99 OTHER <br /> r <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I oT II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.E II.E ill, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# I FACILITY# <br /> m � r <br /> LOCATION CODE,-OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DIS AfCIyPOOE -OP-TIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(NN) `, 14'� FOR0033A-R7 <br />