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STATEOFCAUFORMA QO <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OFINFORMATIONQ 7 PERMANENTLY CLOSED SIT^'ET <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT � S TEMPORARY SITE CLOSURE �s9'- <br /> 1. FACILITY/SITE INFORMATION d ADDRESS-(MUST BE COMPLETED) <br /> OR FACILITY NAME q NAME OF OPERATOR <br /> A RESS N REST SS STREET PARCEL#(OPTONAL),2 e - ©63 -b / <br /> CityNAME L / STATE 9 PHO Es WITHAREACODE <br /> JTC'oJ..�Yv��_ <br /> CAI 3 a 2-1 a- <br /> TO INDICATE BoxO CORPORATION IYI INDIVXXML I�PARTNERSHIP 0 LOCAL�TNCTB NCY O COUNTYAGENCY' O STATE-AGENCY' I� FEDERALAGENCY• <br /> N wvner d UST Is a pubic agency,00nPlete the foEm•Mg:narne of Supervaor of division.section,or oNlos which OWN"IM UST <br /> TYPE OF BUSINESS GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN s OF TANKS AT SITE E.P.A I.D.a(gNJaW/ <br /> 0 3 FARM = 4 PROCESSOR 5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS:NAME T,FIRST) PHONE WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE I WITH AREA CODE <br /> ZZ- <br /> NIGHTS:NAME(LAST,FIRST) PHON ITH AREA NIGHTS: NAME(UST,FIRST) PHONE I WITH AREA CODE <br /> � I <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDLTRE'SS ,J/q ✓bab610ica Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> C G /T l..I rQ (.E • O CORPORATION O PARTNERSMP O COUNTYdGENCY O FEDERAL AGENCY <br /> CITY NAAIF_• STATE ZW PHONE I WITH AREA CODE <br /> f7 / CL <br /> III. TANK OWNER INFORMATION-(MUSf BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> t �- <br /> MAILING ORSTREET ADDRESS or <br /> ✓ boa bkdams, INDIVIDUAL ED LOCAL-AGENCY [=I STATE AGENCY <br /> O CORPORATION PARTNERSHIP Q COUNTY-AGENCY =FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cal((916)322-9669 if questions arise. <br /> TY(TK) HO F4 4- - a a. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm bbStW l�t SELF-INSURED (]2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> O 6 LETTER OF CREDIT Q 6 EXEMPTION 0 IN 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, 111.0 <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) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTYI JURISDKTKNI• FACILITY t <br /> LOCATION CODE OPTIONAL CENSUaff: -�P IONAL SUPVISOR-DISTRK:T000E TIONAL <br /> C} a t (YD <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• M B,UNLESS THIS IS A CHARGE OF SITE INFORMATION ONLY. <br /> FORM A(3'93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 1.41 (;%, <br /> I <br /> �ol�� %�L`7 <br />