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a <br /> Iwo <br /> STATE OF CAUFORMASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILTfYISITE <br /> MARKONLY O I NEW PERMIT 3 RENEWAL PERMIT B CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE12 SIE <br /> ONE REM Q 2 INTERIM PERMIT F--1 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> 102 711-I 11-I NAME NAMEOFOPERATOR <br /> ADDRESS NEAREST CR03S TREET PARCEL*(OPTIONAL) <br /> CITY NAME S4TrATEZIP CODE I 37E PHONE WITH AREA CODE <br /> CA <br /> TO INDICATE (]Box CORPORATION f 1 INDIVIDUAL f�PARTNERSHIP O LOCALAGENCY CDUNTY M)ENCY' OSTATE-AGENCY' tUL#GENCV' <br /> DISTRICTS' <br /> If owner d UST Is a public agency,complete the foloWng:name of Supervbor of dNbbn,section,r office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORQ R/ IIFFVADpN f OF TANKS AT SITE E.P.A. 1.D.s(apthW) <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE f WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> N04TS:NAMEIi 64ST.FIRtM ONE f WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE f WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ING OR STREET ADDRESS ✓ bor binENab O INDIVIDUAL E::] LOCAL-AGENCY C::]STATE AGENCY <br /> Q CORPORATION = PARTNERSHIP O COUNTYAGENCY E:1 FEDERAL AGENCY <br /> CITY NAME STATE ZIP / - PHONE f WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING ORS BEET ADDRESS ✓Eos to YlENrs INDIVIDUAL Q LOCAL AGENCY STATE AGENCY <br /> O CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 -n��C 9 G +d94? <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ <br /> box bbecW O I SELF-INSURED O 2 GUARANTEE O 3 1NSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O a E%EMPTION m OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: Le 11.0 III. <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 E SIGNED) OWNER'S TITLE DATE MGNTHADAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IF JURISDICTION S FACILITY i <br /> 2141 © a / / IV I <br /> LOCATION CODE- T10NAL CENSUSTRACT•-OPSUPVISOR-OISTRICT OWE-OPTIONAL. <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,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 /> FORM A(3513) <br /> Fg10m3AA7 <br />