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1 <br /> • � 66OVq � <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 49 a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA ,� t s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °•�.aR�`' <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE Z <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OP ATOR <br /> r <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE / SITE PHONE#WITHCODE I/ BOX <br /> Z <br /> TO INDICATE f]CORPORATIONINDIVIDUAL (�PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' E�:]STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> It owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS `Y—" t GAS STATION [:] 2 DISTRIBUTOR 0 RESERVATIONINDAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <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,FIRS PHONE##WIITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 7b — o OD/ Zi <br /> NIGHTS: NAME(LAST,FIRST) / PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> f3/- Z_t/y <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S ,'.-� Cir .••� <br /> MAILING OR STREET ADDRESS ✓box bindicateDIVIDUAL I] LOCAL-AGENCY STATE-AGENCY <br /> S6 CORPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAMEww I G�� STATE ZIP CO� PHONE#WITH AREA CODE <br /> S/�l/s, <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> ED CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE--fZIP 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- - Z 6 <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 0 311IN5URANCE 04 SURE BOND <br /> D 5 LETTER OF CREDIT i]6 EXEMPTION 99 OTHER � .CiJ <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: 1. It. III. <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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3F-7 z I <br /> LOCATION CODE -OPTIONAL a CENSUS TRACT# -OPTIONAL SU 2SOR-QISTRICT CODE-OPTIONAL <br /> THIS FORM MUST BE ACC MPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI.ON ONLY. <br /> FORM A(3193) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATRAM <br /> �\ -R7 <br /> 1 <br />