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qF <br /> 771 <br /> 72 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W m�� a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT ,5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE <br /> ONE REM E:] 2 INTERIM PERMIT E�:] 4 AMENDED PERMIT `❑ 6 TEMPORARY SITE CLOSUFIE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D84 OR FACILITY N <br /> AD yr + NEAREST CROSS$TREET PARCEL#(OPTIONAL.) <br /> Dow Irv'. .`. T <br /> t CI1Y' « .:` STATE ZIPOODE SITE PHONE#WI CODE <br /> Box _. <br /> 4 <br /> CORPORATION []INDIVIDUAL LOCAL-AGENCY t�! <br /> TO INDICATE []PARTNERSHIP DISTRICTS' ©COUNTY•AGENCY' STATE-AGENCY' [� FEDERAL-AGENCY' �y <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the LIST •- e,,y <br /> A TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(clot el) r <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR5-OTHER OR TRUST LANDS <br /> z, EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON{SECONDARY)-'optional <br /> u <br /> D Y : NAME(LAST,FIRST) PHONE#�WITH AREA CODE: DAYS: NAME(LAST,FIRST) "py �PHwONE 0{WAIT REA CODE t <br /> ` ",� C� �a{a�� ' �� '"4 a /"�•����� f�7� ice.�s <br /> NIGHTS; FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) " PHONE#WITH AREA CODETG) , <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> t <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS' ✓box b Indicate t <br /> ,r•�� _ <br /> t INDIVIDUAL � LOCAL-AGENCY [ ]$TATEAGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY ,# <br /> CITU NAME STATE ZIP MODE PHONE#WITH AREA CODE <br /> C4 � � <br /> III. TANK OWNER INFORMATION-(MUST BE COMEME <br /> NAME OF OWNF�B r I 9OF:ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate 0 INDIVIDUAL LOCAL-AGENCY E:1 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY E:�] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLET <br /> ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate <br /> [] 1SELF-INSURED Q 2 GUARANTEE 3 INSURANCE E�j 4 SURETY 80ND <br /> 5 LETTER OF CREDIT 6 EXEMPTION Q 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: <br /> x =' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,B TRUE AND CORRECT A <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE. DATE _ MONTWDAY/YEAR <br /> t LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# L FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS•OPTIONALSUPVISOR-DISTRICT CODE-OIPTIOMAL A <br />` THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATK?N ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK>e1S . <br /> FORM A(3/93) • FORDWA•11117 . <br /> ' *• aw p r <br /> s. ... .. •.. phut x• avlx`�5.�...x..u)?. ..m ..a�,eetiv.. ylA id. .vi�1\r.:s.. <br />