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a <br /> STATEOFCAUFORNIA�' STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> 1. FACILITYSITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FI&KITY NAME NAMEOF R <br /> ADD 83 WI'"r�o I NE}SEBTCR STR PMCEL#(OPTONAD <br /> CITY NAME - STA „L ZIP 0011;y : 9 PypN I A <br /> CAX471!/Y!A <br /> TOINDICRTE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP DSTARICTS LOCL-AGENCY COUNTY-AGENCY' OSTATE-AGENCY' C::] <br /> FEDEWI4AGENCY' <br /> N owner d UST Is a public agency,wavists the following:name of Supervisor d olwblon,section,m office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATIONQ 2 DISTRIBUTOR fl,/ IF INDIAN a OF TANJ�AT SITE E.P.A. I.D.a(ayNmeg <br /> 3 FARM 4 PROCESSOR Q 6 OTHER OR TRUST LANDS //v_ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �] <br /> NIGHTS:NAME(LAST,FIRST) PHONE a 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 /> MAILING OR STREET ADDRESS ✓bMbb&ab O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> aW f�CORPORATION = PARTNERS14P 0 COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ NWIDWINAO D INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> f�CORPORATION O PARTNERSHIP COUNTYAGENCY Ij FIUIETULAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQF4 4- - y I i�l'LJJ JJ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ borbindinle E�:] 1 SELF-INSURED �;IGUARANTEE 0 3INSURANCE [:j 4 SURETY BOND <br /> =5 LETTEROFCREDIT LZ 6 EXEMPTION = Le OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[=] II.V III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURIS�N � �Z FACILITY <br /> LOCATD DE -OPTIONAL CENSUS TRACT# -OPTION, -00 BUPVISOR-DISTRICT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THISIS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) FCROOJLA� <br />