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STATE OF CAUFOPHA STATE WATER RESOURCES CONTROL BOARD A maw UNDERGROUNDRAGE TANK PERMIT APPLICATION- F STO CATIO ORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANE CLOSED SITE 2 INTERIM PERMIT 4 AMEN M ONE ITEM ❑ ❑ DED PERMIT ❑ 8 TEMPORARY SITE CLOSURE L FAC1LrrY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME , NAME OF OPERATOR ' ADDRESS NEAREST CROSS STREET PARCEL s(OPTIONAL) 275z.) we—:s±i t TV- CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE TOOINDICx CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL•AGENCY Q COUNTY•AGENCY' Q STATE AGENCY Q FEDERAL-AGENCY DISTRICTS' I owner d UST Is a pubic agency,complete the following:named Supervisor of division,sedan,or office which operates the UST TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.a(apticnap RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMMY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS:NAME(LAST,FIRS PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 1g 91(p_ I(o_77jq - 13- P Lil ARJ�-i a0 -lllt NIGHTS: NAME(LAST,F1W PHONE s WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME /— CARE 9F ADDRESS INFORMAT N MAILING OR STREET ADDRESS ✓box b Wdicate n INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 6201 ^ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE ATTLE 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CALE OF ADDRESS INFOR TIO 1 CA- MAILING OR STREET ADDRESS ✓box"di"Is I = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY ( 1 J '! POPATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE J � IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - (Q V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box bindwate t SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ 11.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT N NARINT� OWNER'S TITLE EVI M71:7/ TH/DY /YEAR LOCAL AGENCY US NLY COUNTY# JURISDICTION# FACILITY tt' a U a , I LOCATION CODE -OPTXOAW CENSUS TRACT s -OPTIONAL SUPVtSOR-DISTRICT CODE-OPTIONAL 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 GROUND STORAGE TANK REGULATIONS FORM A P1114) OWNER