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71 <br /> 77 7 <br /> 6 � k <br /> STATEOFCAUFORMA <br /> l STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> r COMPLETE THIS FORM FOR EACH FACILITY/SITE `'tifoRN` <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 ;I`AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME s NAME OF OPERATOR <br /> ADD NEAREST CROSS STREETPARCEL#(OPTIONAL) 9 <br /> CITY NAME STATE ZIP CO SITE PHONE#WITH AREA CODE <br /> CA 1 <br /> ✓ <br /> BOX <br /> CORPORATION (�INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' (� FEDERAL-AGENCY' <br /> TO INDICATE 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 /> ,q <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> /.0 3 FARM4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> r <br /> i <br /> ------EMERGENCY CONTACT PERSON (PRIMARY) - -- EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ;GAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM ECARE OF ADDRESS INFORMATION " <br /> r f <br /> MAILING OR STREET ADDRESSt` ✓ box b Indicate INDIVIDUAL (� LOCAL-AGENCY STATE-AGENCY <br /> S77 <br /> s <br /> 0 <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY [� FEDERAL-AGENCY <br /> CITY NAME " STATE, ZIP CODE PHONE#WITH AREA CODE <br /> AAX <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 /> 0 CORPORATION PARTNERSHIP (] COUNTY-AGENCY 0 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 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate (� 1 SELF-INSURED o 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> 5 ?, <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.O if. 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 MONTH/DAY/YEAR ; <br /> LOCAL AGENCY USE ONLYThi <br /> -. <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL 3UPVISOR-DISTRICT CODE-OPTIONAL <br /> THIS 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(3193) �tnn (//{� FOR=3A-R7 <br /> ��f✓.�I I ,�� � +�"� 1�f #-.s ,rte. � s.�.r <br />