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- - A <br /> 71,11111m F� <br /> m INV <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD as k <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F7 f NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSEDSITE <br /> ONE ITEM 2 INTERIM PERMIT E::] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE — <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO&FACILI NAME NAME OF OPERATOR <br /> 14A <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> I - <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TNDBICATE h CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' (] STATE•AGENCY' 0 FEDERAL-AGENCY f <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> i <br /> TYPE OF BUSINESS = t GAS STATION = 2 DISTRIBUTOR E� ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.t 1CP6 4 <br /> RESERVATION <br /> 3 FARM = 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> 4c <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> �: 1% aA(4)V/_„� cyvn�T <br /> I <br /> MAILING OR STREET ADDRESS w ✓ box to Indicate E:1 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATrA ZIP CODE PHONE f<WITH AREA CODE <br /> �--- 9 <br /> UL TANK OWNER INFORMATION-(MUST BE COMPLETED) - <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> All <br /> MAILING OR STREET ADDREESSr�} ✓box to indicate INDIVIDUAL 0 LOCAL 0 STATE-AGENCY <br /> P X ( G%#/" CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EWALIZATIAON UST STORAGE FEE ACCOUNT NU BER-Call(916)322-9669 if questions arise. . <br /> TY(TK) HO 4 4 - <br /> Y: PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxbindcate O 1 SELF-INSURED Q 2 GUARANTEE []3 INSURANCE (�4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION 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 /> [CHECKE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> JOWNER'SNAr1iE(PRINTEDBSIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION i FACILITY <br /> LOCATION CODE -OPTIONAL CEN 0VRAqT 1-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPUCATm- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR <br /> MATKNi ONLY. <br /> OWNER MUST FILE.THIS FORM W THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU ORAGE TANK REGULATIO04 <br /> FORMA(3/93) FOR6633A-R7 <br />