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STATE OF CALIFORNIA .� ti <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA "c <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE � °'�,�oa�'' <br /> NARK ONLY F1_1 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM F-1 2 INTERIM PERMIT Q A AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OFA OR FACILITY NAA NAME OF OPERATOR <br /> n <br /> ADDRESS v <br /> NEAREST CROSS STREET PARCELO(OPTIONAU <br /> CITY NAME S eT CA ZI�e7491TE PHONEa WITH R COO l <br /> Box <br /> TOINOCATE CORPORATIONAL O PARTNERSHIP DLSTRCTLOCAL-AGENCY COUMY#GENCY• O STAII/TE/AVLGENC76V• O FEDERAL I)ENCY' <br /> X owner d UST Is a public agency,corrplela Ute following:name of Supervisor of division,eectlon,or office Which OPeratea the UST <br /> TYPE OF BUSINESS O i GAS STATION 0 2 DISTRIBUTOR / IF INDIAN RESERVATION IS OF TANKS AT SITE E.P.A. 1.D.a(cpMmall <br /> Q 3 FARM Q 6 PROCESSOR ER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> /N <br /> MAILING OR STREET AMREST <br /> ,p ✓ bobindkcb INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> �,/ CORPORATION D PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME I / / STATE ZIP CODE�^ PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION`-((MUST BE COMPLETED) <br /> NAME OFOWNER CARE OF ADDRESS INFORMATION <br /> Vvr""C <br /> MAILING OR STREET ADDRESS ✓ bull bindcab INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> ED CORPORATION O PARTNERSHIP 0 COUNTY AGENCY E-1 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓yoc bffWWW I=1 SELF-INSURED D 2 GUARANTEE [__1 3 INSURANCE D A SURETY BOND <br /> ED 5 LETTER OF CREDIT 6 EXEMPTION O Ip 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 ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNERSTRLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY (� <br /> COUNTY# JURISDICTION# FACILITY 0 <br /> LOCATION CODE i� ION L CENSUS TRACT# - SUPVISOR-DISTRICT CODE -OPnOAm <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS CHANGE&SITE RFORNAmhl ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIS <br /> FORM A(393) FORW73A-R7 <br />