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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD czou" ey UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR q 3 xG-i e COMPLETE THIS FORM FOR EACW FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ONE ITEM ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATION o„ ❑ 2 INTERIM PERMIT a AMENDED PERMIT ❑ T PERMANENTLY CLOSED SITE DBA 0 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED1 TEMPORARY SITE CLOSURE o /J�p vf� NAME OF OPERATOR ADDRESS 5• CITU NAME ," I� NEAREST CROSS STREET PARCEN OPrpNA CA ZIP CODE v Box ITE PHQNE p yyl7y{ Ea^,,,,p TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 DSTRIC SENCY Q COUNry-AGENCY 0 STATE-AGENCY TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR ED FEOER4L-AGENCY ❑ 3 FARM O 4 PROCESSOR/ O R SERVATION AN #OF TANKS AT SITE E.P.A. I.D.#(opliplal) 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)•optional PHpNE#WITH AR CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME( AST,FIRST) •�� i r. PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHOMF A WITH I BE 4 COOP II. PROPERTY OWNER INFORMATION- NAME MUST BE COMPLETED y / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS Z 3 ? L ✓box to ndkats V �Q OIVIDUAL Q LOCAL-AG ENCY CITY NAME Q CORPORATION (]STATE-AGENCY 0 pgRTNEgSHIP 0 COUMYAGENCV AC FEDERAL-AGENCY STATE ZIP CODE PHONE G PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) AGF OWNE� M ��✓ �� ,!/y^ INFORMATION MAILIILI CARE OF ADDRESSNG OR STREET DRESS CG �D. ✓ box WIndkNDIVIOUAL ate 0 LOCAL-AGENCY CITY AME STATE E RPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 STATE-FOERAGENCY ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY JK) HQ [4-F4]- V. 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bUbWicala 0 I SELF-INSURED 0 2 GUARANTEE O 5 LETTER OF CREDIT E711 6 EXEMP ON O 3 INSURANCE O A SURETYBOND 0 99 OTHER VI, LEGAL N071F1CA7)ON AND B1LL)NG ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ rH/S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRVECT APPLICANTS NAME(PgINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWOANEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION N �—�J FACFA�C�IL7IT�Y/# LOCATION CODE -OPTIONAL CENSUS TRACT - L I I/if�/I UI 71 5/ ` 4 - I2- O OPTIONAL SUPVISOR-DISTRICT CODE -OP—TIONAL z3. 5 4Z THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(S-91j FOR0033A.5 r l� L f ko