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C , <br />2 <br />CyOUSCr� <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD W dam, <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF iNFORMA`r1OW 7 PERMANENTLY CLOSED. SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />t 60 <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />V5 kd L� <br />t <br />ZIP CODE <br />CITY NAME <br />STATECA <br />ZJ� CODE <br />SITE PHONE # WITH AREA <br />PHONE# WITH AREA CODE <br />/CODE <br />✓ BOX (] CORPORATION ® INDIVIDUAL U21PARTNERSHIP Q LOCAL -AGENCY ®COUNTY -AGENCY' STATE -AGENCY' Q FEDERAL -AGENCY° <br />TO INDICATE DISTRICTS <br />° N owner of UST is a public agency, complete the following: name U supervisor of division, section or office which operates the UST <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />® ✓ IF INDIAN <br />I# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM ® 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />CONTACTEMERGENCY •N (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)optional <br />11. <br />`•` OWNER INFORMATION• !'' <br />N <br />CAR A DRES FORMATION <br />CAaF OF ADD SS INFORMATION /+ <br />�" 2_ <br />LI O TREET ADDRESS <br />. 1150K 102a- <br />✓ box to indicate DIVIDUAL LOCAL -AGENCY ® STATE -AGENCY <br />= CORPORATION Q PARTNERSHIP COUNTY -AGENCY Q FEDERAL -AGENCY <br />CI NAME <br />S TE <br />ZIP CODE <br />PHONE #WITH AREA CODE <br />414 1 <br />Ill. TANK OWNER INFORMATIONCOMPLETED) <br />NA OF OWNER <br />r <br />CAR A DRES FORMATION <br />MAILING OR STBEET ADDRESS <br />✓ boxto indicate DIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />Co- <br />® CORPORATION Q PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />ST E <br />Z C E <br />PHONE# WITH AREA CODE <br />'04ga -- 141 <br />✓ box to indicate a 1 SELF-INSURED = 2 GUARANTEE ® 3 INSURANCE ® 4 SURETY BOND = 5 LETTER OF CREDIT ® 6 EXEMPTION STATE FUND <br />(� 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER ® 9 STATE FUND & CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM ® 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. E] 11. a 111. 0, <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME (PRINTED & SIGI <br />LOCAL AGENCY USE ONLY <br />DATE <br />IBM <br />COUNTY # JURISDICTION # FACILITY If <br />m <br />LOCATION CODE - OPTIONAL CENSUS TRACT ft - 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! i •#. •..•REGULATIONS <br />, <br />