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6Ma-C. STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD W 4,¢ ' n S UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA COMPLETE THIS FORM FOR EACH FACYLTIYISITE 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 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME I UJ I it q NAME OF OPERATOR Yf a AOD ESS NEAREsY CROSSSTRE T ARCELX(OPTIONAu CITY NAMES0 C_ STATE ZIP CODE SITE PHONE it WITH AREA CODE CA V BOXCORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY 0 COUNTY�AGENCY' O STATE-AGENCY' Q FFDERAL-AGENCY' TO INDICATEE71 DISTRICTS' I1 owner of UST is a public agency,complete the following:name of Supervisor of division,section,or offios which operates the UST TYPE OF BUSINESS 1 GAS STATION L2 DISTRIBUTOR O ✓ IF INDIAN d OF TANKS AT SITE I E.P.A. L D.*(°phonal) RESERVATION Q FARM 0 4 PROCESSOR [7] 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRS PHONE (I A E COD NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME _ CARE OF ADDRESS INFORMATION O MA4LING OR STREET ADDRESS `/ box-indicate IQ INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CQ CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NA E STATE ZIP CODE PHONE X WITH AREA CODE C Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE I WITH AREA CODF IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box-indicate r_� f SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE 4 SURETY BOND i Q 5 LETTLA OF CRED[T 6 EXEMPTION Q 99 OTHFR VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ll 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 OWNER'S NAME(PRINTED&StGNED) OWNER'S TITLE DATE MONTHIDAYIYFAR LOCAL AGENCY USE ONLY r r _'r h COUNTY# JURISDICTION# FACILITY# F IBJ LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL 9UPYISOR-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 FlOaa3A-R7 FORMA(3183)