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r <br /> �• i <br /> STATE OF CALIPoRMA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD •"� .a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM .o^ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION O 7 PERMANENTLY <br /> MARK ONLY 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> ONE REM O 2 INTERIM PERMIT <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BECOMPLETED) <br /> nRA 09 FACILITY NAME _ <br /> NEAREST CROSS STREET PARCEL a(OPTIONAU <br /> ADDRESS 00 <br /> STATE ZIP DE SITE PHONE#Wit H AREA LADE <br /> CITY NAME'S P CA <br /> ✓-- c, LOCAL-AGENCY COUMKAGENCY' O STATEAGENCY' 0 FEOEML-AGENCY' <br /> T I/ Box I�CORPORATION Q INDIVIDUAL I�PARTNERSHIP 0 LOCDIST - ' <br /> If owner of UST is a public agency,complete the following:name at Supervisor of tlMlAbn,sectbn,or office whbheper operates <br /> the <br /> #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR RESERVATION ' <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAV.KAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> K 1Y PHONE 1 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> to r e Y7 C ✓ boxbindii Q INDIVIDUAL LOCAL AGENCY 0 STATEAGENCY <br /> MAILING ORSTREET ADD ESS =CORPORATION =PARTNERSHIP COUNTY-AGENCY 0FEDERALAGENCY <br /> STATE ZIP CODE PHONE If WITH AREA CODE <br /> CITY NAME <br /> L_ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> �(yE•Fw a/Q� ,/ bor binEkale Q INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION <br /> O PARTNERSHIP O COUNTY-AGENCY FEOEML-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITU NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I�1 SELF-INSUPEO 1�2 GUARANTEE O 3 INSURANCE O a SURETY BOND <br /> ,/boabMkate Q 5 LETTER OF COEDIT l�6 E%EMPTION 97 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Eg it.= It. <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) <br /> OWNERS TITLE DATE ---.,"YEAR <br /> OWNERS <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION# 'ILiPYI <br /> 7-OPT170NAL <br /> # <br /> oLOCATION CODCENSUS TRACT# -OPTIONAL <br /> BUPVISOR-DISTRICT E -OPTIO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMA UNDERGROUND <br /> D ST IS A CHANGE OF SITE INFORMATION ONLY.q,f �, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STOR;AGE TANK REGULATIONS �' �S1#l7 <br /> FORM A(393) <br /> ko,) -rasfG� e V <br /> a% h i I / T� T 'd f�it.e c d �p �c, ) l< t- <br /> 4- <br /> <D If. <br />