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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 ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(M ST BE COMPLETED) <br /> DBA OR FACID NAME 144.tOPERATOR <br /> `7 <br /> ADDRESS NEAREST CROSS STREET PARCB-#(OPTIONAL) <br /> 5 S. <br /> CRY N STATEZPPOQE I SITE PHONE#WITH AREA CODE <br /> CA �I.w�c, /� <br /> 6,BOXO CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY L[-I cDUNTY-AGENCY' D STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> &creamer of UST oe Pobeo a9exy.ompbte the foOnehg name,of supervisor of 6v#hn,section orof8oe which operates the UST <br /> TYPE OF BUSINESS FT9 I GAS STATION ❑ 2 DISTRIBUTORO ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS' <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> : NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> il. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bozbiidmta Q INDMDUAL LOCAL-AGENCY O STATE AGENCY <br /> Q CORPORATION 0 PARTNERSHIP a COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME <br /> STA&A_ I ZIP CODE 2&(;=e <br /> q PHONE R WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM FOWNER CARE OF ADDRESS INFORMATION <br /> SGQ,t.,) <br /> V <br /> MAILIOR STREET ADDRESS ✓ boxlohdimle Q INDIVIDUAL0 LOCAL-AGENCY O STATE-AGENCY <br /> AStoo =CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q 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) HQ 4 4 - Q Q 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓baxbidoa Q I SELF-INSURED =2 GUARANTEE =3 INSURANCE O 4 SURETY BOND O 5 LETTER OF CREDIT I1 8 EXEMPTION =7 STATE RIND <br /> O8STATE FUND&CHIEF FINANCIAL OFFICER MIER O9 STATE FUND&CERTIFICATE OF DEPOSIT Q10LOCAL GOVT.MECHANISM 099 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.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �j—F�AcCIIL�ITTYYYq#' 4 � <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -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 /> FORMA(695) <br /> OWNER MUST FILE THIS FORM`/'THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI 1.04'TORAGE <br /> /TORAGE TANK REGULATIONS <br />