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a STATEOFCAUFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILrrY/SITE MARK ONLY E�i. t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE /J- I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME / NAME OF OPERATOR L ADD ESS / NEARES CROSS STREET PARCEL#(OPTIONAL) Ul CITU NAME STATEZIP TE PH E•WITH AREA CODE I/ Box CA 9 L 7-3 TO INDICATE 0 CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY• O STATEAGENCY' O FEDERAL-AGENCY' DGTRCTS' H owner of UST Is a public agency,conplete the following:name of Supervisor of division.section,or office which operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(optimal) 3 FARM 6 PROCESSOR 5 OTHER RESERVATION ❑ ❑ OR TRUST LA ION EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY ' NAME ST, IRST) ONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#_WITR AREA CODE ` NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILI OR TREEI ADDRESS ✓ Oo6 blMbate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 'Z COflPoRAnON 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY AMBfr� S�A ZIP CODE �l ONEa WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) V 3 NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR RE'E�T/ADDRESS �rv�,6 ✓box biMkaM 0 INDIVIDUAL O LOCAL STATE AGENCY 6(1 I v' �T CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY E_:j FEDERAL-AGENCY CITYA 1 � STAN ZIP CODE 2_� L' WITH AREA CODE_ , 3 _/Op'• 2tJ�/�J IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4—]74- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bot bygbys 0 t SELF INSURED 0 2 GUARANTEE O 3 INSURANCE O A SURETY BOND ID 5 IETTEROFCREDIT D 6 EXEMPTION D 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.X 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&SIGNED) OWNER'S TITLE DATE MONTWDAW/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a LOCA_TK)N CODE -OPTIONAL CENSUS TRACTi -OPTIONAL FS -DISPAICT CODE -OPTIDNN. L2- T S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM Br UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A tM) FOPAMMA/