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t6oURCe STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 UN RGROUND STORAGE TANK PERMIT APPLICATION -FORMA .Im lo r MPLETE THIS FORM FOR EACH FACILrrY/SITE E MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT E�]� 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE ONE ITEM F_ 1 2 INTERIM PERMIT L_� 4 AMENDED PERMIT EJ 6 TEMPORARY SITE CLOSURE h::� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR C.�A n e p- 9 (�Gi. r G�.%G�. s NIGHTS: NAME (LAST, FIRST) ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE CA 5 Zd/ ZZ29 ✓ BOX TO INDICATE CO PORATION [] INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY 0 STATE -AGENCY [71 FEDERAL -AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) RESERVATION O 3 FARM U 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - omional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED), NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME — STATE ZIP CODE PHONE # WITH AREA CODE III. I ANK UVVNtK INt-UHMA I IUN - (MU51 bt (:UMF'Lt I tU) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY 0 CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE I ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. TY (TK) HQ V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate r 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND 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 the CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ H. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # 2 1 71 1 LOCATION CODE OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL Of ?i3� 3l3 Gl%�1f3 �� THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS// &/ FOR0033A-R6 0 40 �/