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STATE OF CAUPORNIA 'o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMA COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ d NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED 917E ONE REM ❑ 2 INTERIM PERMIT F-1 \ SITE CLOSURE 4 AMENDED PERMIT ❑ e TEMPORARY SI I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME I NAME OF OPERAT R 1{ ADORES NEAREST CRO SS STREET PMCEL#(OPrKINAy CITY ME STATE ZIP CODE 31 PHONE%WITH AREA CODE CA Ini ;- ✓ BOXFNOV TOINOCATE D CORPORATION D INDIVIDUALPARTNFASHIP LOCAL-AG O �UNfV-AGENCY' OSTATE-AGENCY' 0 FEDERAL-AGENCY' DISTRICTS' •x owner of UST Is a public agency,complete the following:name o Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.#(cphonal) ❑ ❑ RESERVATION ❑ 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 7: PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BECOMPLETED CARE OF ADDRESS INFORMATION NAME MAILING OR STREET ADDRESS ✓boa bindbale [--1 INDIVIDUAL =LOCAL-AGENCY E]STATE-AGENCY CORPORATION = PARTNERSHIP O COUNTY-AGENCY =FEDERAL-AGENCY# CITU 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 ✓ box b indicate O INDIVIDUAL 0 LOCAL-AGENCY I�STATE-AGENCY Q CORPOMTION O PARTNERSHIP COUIRYw1GENCY O FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 W- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box bbdica 0 i SELF-INSURED 2 GUARANTEE Q 3 INSURANCE (]4 SURETY BOND D 5 LETTEROFCREDIT a EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= it.= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIOAY/YEARp LOCAL AGENCY USE ONLY ' " ` COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM3AA7 FORM A(353)