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maw• r <br /> STATEOFCAUFORNA v^' ti <br /> STATE WATER RESOURCES CONTROL BOARD a� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , <br /> COMPLETE THIS FORM FOR FACILr YISITE °•�,.,..�' <br /> MARK ONLY F7 I NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F] 7 PERMAN _ D SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q A AMENDED PERMIT L_. S TEMPORARY SITE CLOSURE <br /> I. FACILTTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OSA4aR FACILITY NAME NAMED ERATOR <br /> r <br /> ADDAEVS NEARSTCROSSS EET PARCEL/(OPfDNAU <br /> CITY E STATE ZIP CODE SITE PHONE/WRH AREA CO DE <br /> CA — <br /> TOINOICATE C3 CORPORATION INDNIDUAL Q PARTNERSHIP LOCM,-T3' Y COUNTY'G' Y'NCQ STATE.AGENCY' 0 FEDEAAL.IGENCY' <br /> DSMC <br /> ff oemer d UST i/a pubic agenly.conPire INe Iokry g:.d SupavlFa of&Woof.aeetbn,w office w ieb pprale,the UST <br /> TYPE OF BUSINESS 1 GAB STATION Q 2 DISTRIBUTOR (] J IF INDIAN a OF TANKS AT SITE E.P.A I.D.a Iopt ) <br /> RESERVATION <br /> Q 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OukYj NAME(LAST,FIRST) PHONE/WI EA CODE DAYS: NAME(LAST,FIRS4PH9NE.WITH AREA CODE <br /> N S: NAME(LAST.FIA P E a WITH AREA CODE A NIGHTS: (LAST, IRST) PHDNESWITHAREACOOE <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> MMLWGOR STREET DRESS •1 Dpi b/IWrar INDIVIDUAL LOCAL AGFNCY I_' STATE-AGENCY <br /> �, a CORPORATION (] PARTNEASHP COUNTY-AGENCY Q FEDEMLAGENCY <br /> CITYNAM STATE /WITH AREA CODE <br /> 1 <br /> III. TANK 0 NER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF NER CARE OF ADDRESS INFORMATION <br /> MAILING OR <br /> STREET ADDRESS pr bNYrLe INDNCUAL LOCAL-AGENCY C STATE-AGENCY <br /> Q CORPORATION a PARTNERSHIP a COUNTY-AGENCY (=' FMORAL.AGENCY <br /> CRY NAME - STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Dor bitlkaY (]1 SELF-INSURED (]2 GUARANTEE CJ 3 INSURANCE Q a SURETY BONO <br /> O s LETTEROFCREDR ]A EREIAPnON C 3B OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless ho II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Gpl� [L= III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE&EST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNERS TIRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> I r <br /> COUNTY x JURISDICTION s FACILITY s <br /> ml =E4 <br /> LOCATION CODE -OPT)ONAL CENSUS TRACT -OPInCNAL SUPVISOR-DISTRICT CODE •OPTAOAM4 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(3)OR MORE PERMIT APPLICATION• FORM Br UNLESS THIS tS A CHANGE SRE NFORMA N <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY WPLEWxnNG THE UNDERGROUND STORAGE TANK REGUlLAMM <br /> FORMA(1N3) <br />