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77 7Tw <br /> yew <br /> 1 <br /> Iu- Cs <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ( mfr All,Ao° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-F A <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE <br /> MARK ONLY t NEW PERMIT a 3 RENEWAL PERMIT 56 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY E NAME OF OPERAT R <br /> P►B� 6 4 <br /> ADDRESS INEAR T ROW-43 EET PARCEL#(OPTIONAL) <br /> I <br /> CITY NhME STAfE <br /> /� ZIP COD SITE PHONE#WITH AREA l:Q[ <br /> CA —3. //J) <br /> ✓ BOX CORPORATION (]INDIVIDUAL PARTNERSHIP LOCAL-AGENCY <br /> TO INDICATE DISTRICTS' 0 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY' <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 t GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME J.V CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / ✓box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAM STATELa93 <br /> ODE PHONE#WITH AREA CODE <br /> 20 . sjr --3 <br /> III. TANK OW ER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL = LOCAL-AGENCY I]STATE-AGENCY <br /> Ij CORPORATION 0 PARTNERSHIP = 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate (� 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> (�5 LETTER OF CREDIT 6 EXEMPTION (]99 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: I.[:] II.mr III.a <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 11�1 F= 12J_31 11117,1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-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 /> FORMA(3193) � � wRpp3yt.R7 <br />