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<:yl x ^ `6OUR �3 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W 4a 1 a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA _ y COMPLETE THIS FORM FOR EACH FACILITY/SITE ``L,foRN`' MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY 31 ONE REM O 2 INTERIM PERMIT 71 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) D R FACILITY NAME'. NAME OF OPERATOR r r wr ADD E 3 NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE iCA R BOx RATION I�INDIVIDUAL []PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' [� STATE-AGENCY' I� FEDERAL-AGENCY' TO INDICATE DISTRICTS' ff owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORa IF INDIAN I#OF TANKS AT SITE E.P.A. 1.13#(aptional) RES✓ERVATION 3 FARM 0 4 PROCESSOR I�A 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE N141TS:NAM T,FVMJ PHONE#VOTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE fl. PROPERTY OWNER INFORMATION- MUST BE COMPLETED N CARE OF ADDRESS INFORMATION JkC MAILING OR STREET ADDRM ✓box b Indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY E 3 ATE ZIP CODE PHONE#WITH R ODE I III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME-OF OWNER CARE OF ADDRESS INFORMATION l Y MAILING OR STREET ADDRESS ✓box to Indicate 0 INDIVIDUAL �`. � LOCAL-AGENCY 0 STATE-AGENCY i CORPORATION PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY C STATE ZIP CODE P E# ITH ODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate (� 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT 6 EXEMPTION 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: LE] II.❑ IAL Ex THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# ELOCATIONDE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM FORM A(3(93) FOR0033A-R7