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0 0 a <br /> STATE OF CAUFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH!ACI rTYISITE <br /> MARK ONLY O I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENT=SITE <br /> ONE REM [__1 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CR4 STREET PARCEL 0(OPTIONAL) <br /> CITU NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE <br /> CA q <br /> ✓ eox <br /> T I/ BOX �CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTYAGENCY' O STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> -If owner d UST Is a public agency,�n We,the following:name of Supervisorof division,sedion,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION O 2 DISTRIBUTOR 0 ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.N(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: ME(LAST,FIRST) PHONEN WITH AREA CODE NIGHTS: NAME(LAST,FIRS p PHONEN WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA ` CAREOFADDRESS INFORMATION <br /> L <br /> MAILING OR STREE ADDRESS ✓ box bintlbate D INDIVIDUAL 0 LOCAL-AGENCY E::] STATE AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) /`1Y1 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> W <br /> MAILING OR STREET ADDRESS ✓ box biMkaie Q INDIVIDUAL O LOCAL O STATE AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY AGENCY (] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate D I SELF INSURED (]2 GUARANTEE O 3 INSURANCE =1 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT E:1 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo r II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I,e II.[::] III.❑ <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 MONTH/OAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 2O <br /> LOCATION CODE -OPTIONAL CENSUS TRACTN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(3183) <br /> OWNER MUST FILE THIS FORRW THE LOCAL AGENCY IMPLEMENTING THE UNDERGFIV STORAGE TANKREGNSULATIO/li/� <br /> � C FORO037014' <br /> M ��r <br />