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't e0 � f <br /> STATE OF CAUFORNIA :� c ti <br /> STATE WATER RESOURCES CONTROL BOARD .,�� - o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r aD <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'��•ae+`' <br /> MARK ONLYD NEW PERMIT 0 3 RENEWAL PERMIT F76 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE 02, <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITYNAM OPaPA / NAME OF OPE OR <br /> ADR (/�^ t�eA �f NEAROSS ST EET PMCELN(OPrONAU <br /> CITY STATE 117 <br /> ZIP CO <br /> SITE PHONE i WITH AREA CODE <br /> CA0952 <br /> ✓ B& <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCALAGENCY O COUNTY-AGENCY' O STATEAGENCY' O FEDERAL-AGENCYDISTRICTS- ' <br /> It owner of UST Is a pubbc agency,complete the foboving:name of Supervisor of division,section,or office which operates the UST / 1(5 <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR i� p SEIFVATDIIAN ON #OF /7MI(5 AT SITE E.P.A. I,D.i(gNimeQ <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS `%`1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓butlnaicaN INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> 6N PAP 0 CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDEIMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo%blydicata 0 INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 4 4- 0 3 2 2 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bwtbilN[ale O t SELF-INSURED D 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 5 EXEMPTION O Ns OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Lint 2jbox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL[=] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> C. a JURISDICTION If I9 FACILITY 0311 00 <br /> LOCATION CODE�7 NAL CENSUS TRACTi - T10 SURVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM BBr UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA 1393) �� FOROW3AA] <br /> h�� <br />