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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE: <br /> ONE REM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE T6a <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N AME NAME OF OPERATOR <br /> r <br /> ADD <br /> R S NEARESTCROSS STREET PARCELA(OPrONAD <br /> 0 5• KGF <br /> CITY JAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> z�0 ( ca ge'Z�D <br /> TO INDICATE D CORPORATION E-1 INDIVIDUAL O PARTNERSHIP E=I LOCAL-AGENCY E--] COUNrYAGENCY' [�D STATE.AGENCY' [=] FEDERAL#GENCY' <br /> #owner d USTI$a public DISTRICTS' <br /> p agency,Wn NlatheWMng:na of SUPemisorof d"ion,Section,oroffice whbh operates the UST <br /> TYPE OF BUSINESSFV I GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS qT SITE E.P.A. I.D.0(oylbW) <br /> Q FARM 0 6 PROCESSOR Q 5 OTHER TRUST LANDS <br /> RESERVATION <br /> OR <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•gPTINMI4 <br /> DA NAME(LAST,FIR P E i WITH ARFIS DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -' —�•Lr rr �f��3z-���� <br /> NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �/� ✓bmii INDIVIDUAL I1 LOCAL-AGENCY O STATE-AGENCY <br /> �1DQ <br /> / c> LGPQ V O CORPORATION PARTNERSHIP 0 COUNrYAGENCY O FEDERAL-AGENCY <br /> CITY NAME ( -G� STATE ZIP COD PHONE a WITH AREA CODE <br /> III. TANKOWNER INFORMATION•(MUSTBECOMPLETED) <br /> !�NER CARE OF ADDRESS INFORMATION <br /> MAILINGGOR STREET ADDRESS _ ''�} ✓box 0 fK ica INDIVIDUAL O LOCAI.AGENCY D STATE-AGENCY <br /> / 3 VD- / ��D 'Y M CORPORATION O PARTNERSHIP Q COUNTY-AGENCY [-1 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 4!54 / <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 If questions arise. <br /> TY(TK) HQ [4-f4--]- Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bin..t. O 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE <br /> O A SURETY BONG <br /> 5 LETTER OF CREDIT <br /> S EXEMPTION = gS OTHER <br /> A. 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.O IL Q III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST O ATY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION II FACILITY# <br /> f/y <br /> LOCATION CORS-OPIpAW. 0"Fe OPTIONAL ISOR-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 /> FORMA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> (393) <br /> FOIM0SAA7 <br />