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• • fc6 a <br /> f <br /> STATE OF CALIFORNIA n,•• "o <br /> STATE WATER RESOURCES CONTROL BOARD `�"'g$ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORMA f .,, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE f""°""�� <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT F-1t <br /> 4 AMENDED PERMIT �6 TEMPORARY SITE CLOSURE s: <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> / X74 <br /> NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> ADDRESS <br /> 2SG/ Y.e7/-G 5 i <br /> CITU NAME STATE ZIP P CODE <br /> DE ITE P NE i WITH AREA CODE <br /> CA <br /> 57A-n_*_ a RP Za"T G/ � s4 <br /> T INDICATE0 BEj CORPORATION O INDIVIDUAL PARTNEASNIP 0 LOCAL-AGENCYINSTRUC0 COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> If owner at UST Is a public agency.complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN N!)F TMyCS AT SITE E.P.A. I.D.t(apflanag <br /> ❑ RESERVATION L <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY • NAME(LAST,FIRST) PPONE N WITH AREA DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> CAD <br /> A> xt <br /> MAILING OR STREET ADDRESS ✓ box biMkaN 0 INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bxbinowae D INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O 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) HO F4-F4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0Inskate =1 SELF INSURED Ll 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EnMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �FACILITY# �-J <br /> 7 <br /> LOCATION CODE -OPTIONAL CENSUSr,,1 a •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �- <br /> L -�3 f 1 <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS F "AaT <br /> FORM A(393) • � ��/ ��/�� <br />