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A <br /> STATEWATER RESOURCES CONTROL BOARD + <br /> UNDERGROUNDSTORAGE TANK PERMIT APPLICATION-FORM Aoa <br /> COMPLETE THIS FORM FOR CH FACI' /S ;foR <br /> MARK ONLY M Yl&PERMIT ® 3 RENEWAL PERMIT s CHANGE OF INFORMATION Q 7 RMANENTLY D SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> f <br /> I. FACIL /SITE,INFORMATION&ADDRESS-(MUSTBE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS r( AR EST CROSS STREET PARCEL#(OPTIONAL) <br /> W 9 f2 A4 t-:2 :YO12vv A— <br /> CITY NAME _114 STATE ZIP CODE SITE PHONE#WITH A EA CODE <br /> CA <br /> TO INDICATE Q CA RATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-ACENCY' <br /> DISTRICTS' <br /> If owner of UST is a public age cy,Complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS a t GAS STATION = 2 DISTRIBUTORRESER INDIAN is OF TANKS AT SITE E.P.A. 1.D.#/optional) <br /> Q 3 FARM Q 4 PROCESSOR = 8 OTHER OR TRUST LANDS <br /> 1 <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: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ®CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN 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 ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to Indicals Q i SELF-INSURED Q 2 GUARANTEE F_j 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q N 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: L IL a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KN, E,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) I OWNER'S TITLE DATE MONTY/YEAR <br /> ,7 <br /> za <br /> LOCAL AGENCY USE ONLY �,(/ <br /> IE <br /> / COU JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTlO L CENSUS TRACT# V [ICTOODE_OPnONAL <br /> OP <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER APPUCATM-' ORM ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM a( ) <br /> OWNER ST FILE THE FORM WITH TH THE LOCAL AGENCY IMPLEMENTING T UNDERGROUND STORAGE TANK REGULATIONS -117 <br />