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i <br /> 9 <br /> " fix ^ cbOu- es 11 <br /> STATE Of CALIFORNIA `f tir! •, c <br /> STATE WATER RESOURCES CONTROL BOARD ; ?� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> ft COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> t <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ARA OR FACILITY NAME NAME OF OPERATOR ' <br /> et <br /> ADDRESS NEAREST CROSS STREET.,I PARCEL#(OPTIONAL) <br /> �j 3 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH ARE,,A CODE <br /> CA <br /> I/ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL L ,PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' y <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 f <br /> TYPE OF BUSINESS = 1 GAS STATION [=] 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optronal) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS}NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS:�ME`(LAST,FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e7k <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - i 3 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS . ✓ box to indicate <br /> �r �p_ L, ��1���Y� � INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ' CARE OF ADDRESS INFORMATION " <br /> MAILING OR STREET=tk <br /> ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ,0 k"(S� l�CORPORATION .PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY wp <br /> CITY NAMEA STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORA E FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM'UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION (] 99 OTHER <br /> �r <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 /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNE OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> 1 Y <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIO CO -OPTIONAL CENSUS: *-• L3UPVISOR-DISTRICT CODE-OPTIONAL <br /> 0 <9D iA <br /> IRIS 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 <br /> FORM A(3/93) FOR0033A4t7 <br /> Y <br /> ..u��- <br />