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STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM :mom <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT D 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA CILITYN NAME OF OPERATOR <br /> ADD I NEAREST CROSS STREET PARCEL#(OFrONAL) <br /> CITU N <br /> STATE SITE PHONE#WITH AREA CODE <br /> CA <br /> Box <br /> TOINOCATE CORPORATION O INDIVIDUAL PARTNERSHIP 0 DISTNCTAGENCY COUNTY.AGENCY E7:1 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS 0 I GAS STATION Q 2 DISTRIBUTOR RESERVADION AN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> Q 3 FARM = 4 PROCESSOR Q 5 OTHER 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 rnnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAS 1.FIRST) PHONE#WITH AREA Com <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa binEkah, INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA Door <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bweab 0 INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Oo�bhbicaw D 1 SELF-INSUREDO GUARANTEE D 3 INSURANCE L--34 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION Q W 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 checked. <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# �n JURISDICTION If FACILITY# <br /> LOCATION CODE - TTONAL CENSUSTF!F ; T�L SUPVISOR-DISTflICT OODE -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 /> FORM A(541) / FORW33A-5 <br /> �./L/ <br />