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STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYQLOSED.SITE- ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I .J J I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR i i,9 :, i ADDRESS NEAREST CROSS STREETS (a PARCEL k(OPTIONAQ CITY NAME STATEZI f --i SITE PHONE#WITH AREA CODE iYl rE�v' ; Gcc� CAS �� ✓ Box ORPORATION O INOIVIOUALO PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS 'I ownerof USTis a publk agency wmplete the followng:tame ol supeNsorof dwism.aeciion oro#ice which opeonthe UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEIRVATION FINDIAN #OF TANK SITE E.P.0. I.D.#(optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bo<loed 2 0INDIVIDUAL 1=LOCAL-AGENCYOSTATE-AGENCY O CORPORATION O PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY 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 ✓ buxloindirate D INDIVIDUAL O LOCAL-AGENCY STATE AGENCY O CORPORATION O PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY 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 F4-14-1- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bot to irdicale 0 1 SELF-INSURED Q 2 GUARANTEE =3 1NSURANCE =4 SURETY BOND O 5 UETTEROFCREDIT 0 6 EXEMPTION O 7 STATE FUND 08 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCALGOVT.MECHANISM = 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ IIIO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m� LOCATIONCO,DE-OPTIONAL CENSUS.TRACT# -,OPT,�O�VAL SUPVISOR-DI4T�71IC5 CQDE.5 OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM JTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUOORAGE TANK REGULATIONS FORM A(6-95)