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r ti„ 0 STATE OF CALIFORNIA o STATE WATER RESOURCES CONTROL BOARD W Yc 4 b UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �� , ti COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERWT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY GD SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I, FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAM ( / NAME OF OPERATOR g LL4 ,ate f ADDRESS NEAREST CROSS STREET PARCEL 4(OPTPONAL) CITY NAME STATE ZiP CODE �TE PHONE#WITH AREA CODE CA y<z3 b �t1 7 a ✓ BOX CORPORATION 0 INDIVIDUAL PARTNERSHIP AL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE 0 DISTRICTS' If owner d UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR �EE—�IRESERV ✓ IF INDIAN i1 OF TANKS AT SITE E.P.A. I.D.+e(optional) ❑ ❑ ATION 3 FARM 0 4 PROCESSOR 5 �THERRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS:WMET,FIRS�1 PHONE*WITH ARE ODE 020 �i�'�i' � rl PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LA T,FiRST) € % 24-IFy6 11. PROPERTY OWNER INFO MATION- MUST BE COMPLETED NAM / ! CARE OF ADDRESS tNFOR ATIC MAILING OR STREET ADDFiE$S ✓ box to indicate _] INDIVIDUAL t] LOCAL-AGENCY STATE-AGENCY CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY CI FEDERAL-AGENCY CIN l _2 ---111 STATE ZIP CODE ` ' PHONE A WITH AREA CODE vl C� s Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box W eradicate__j= [:::] INDIVIDUAL OLOCAL-AGENCY E::]STATE-AGENCY [:D CORPORATION ® PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME IP CODE PHONE x WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HCl V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED L-11 SELF-INSURED 0 3 GUARANTEE 3 INS RANGE a RE ,/ boxbindfeate TY,B/OfN/Q)�J CO 5 LETTEROFCREDhT D 6 EXEMPTION 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. CNECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.V 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&SIGNEDI OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT t -OPTIONAL SUPVISOR-DtST ICT CODE •OP170MAL Z:0-- 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 REGULATM FOR (r1 FORMA(3183)