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fCeO UN•-�C STATE OF CALIFORNIA • .` `� STATE WATER RESOURCES CONTROL BOARD W`40 � UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORMA , COMPLETE THIS FORM FOR EACH FACILITY/SITE ��c foRN MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED S ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL N(OFIONAL) az ,civ CITY NAME STATE ZIP CODEPONE#WITH AREA CODE G CA � 36g— I/ BOX TOINDIC TE D CORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' DISTRICTS' If 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 0 1 GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANK 'AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY �NTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE *i:114111_44 I 3;5v-,A --el?-040 -S. 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 bindicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY 1—7 6 AU ,041 V — CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE# ITH AREA CODE Lras�� 9�Zf 3d69 d 6�+ 111. TANK OWNER INFORMATION.(MUST BE COMPLETED) NAME OF OWNER �.��)) ^/� CARE OF ADDRESS INFORMATION 64 �� �/ �%-,54, j4 MAILING OR STREET ADDRESS I ✓box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ! CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE WITH AREA CODE '�z,9 2� 3b�s—060 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 bIndicate O t SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND D 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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: L= II.rV Ill, 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 MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 1W � � 9 LOCATIOIJ CODE -OPTIONAL CENSUS �T# -OPTIONAL SUPVISOR-D TRICT CODE -OPT)ONAL O 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUU711 NS FORMA(3193) � FOR0033A-R7