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D!P ���(( q 74-S <br /> STATE OF CAUFORNIA lD J��S /d 3 <br /> STATE WATER RESOURCES CONTROL BOARD AAll <br /> /V �D 37 <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMA <br /> C/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY C ED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT O s TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION d ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARE TCROSSSTREET PARCEL I(OPTIONAL) <br /> Eel N S <br /> CITY NAME STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> v BOX --..CA 9s' <br /> TOINDCATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTYAGENCY- O STATE-AGENCY' O FFDERALAGENCY' <br /> S wmar d UST Is a pubic agency=V06 the Idlowl d S DISTRICTS ng:name upar'lcor d dNbbn.sectbn,IS oNlea which operates the LIST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR .1IF INDIAN s OF TANKS AT SITE E.P.A. I.D.s(cpfAm ) <br /> O RESERVATION <br /> = 3 FARM 4 PROCESSOq5 0 HER OR TRUST LANDS <br /> // EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opdonal <br /> Cly YS: N E(LAST,FIRST( PHONE WITH A EA DE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: NAME(UST,Flq PHONE a WITH AREA CODE NIGHTS: AME(LAST.FIRST) PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /31'e 6,Wy 6X / <br /> MAILING OR STREET ADDRESS ✓bw b Intik le O INDIYWUAL AUAGENCY ED STATE-AGENCY <br /> CORPORATION I]PARTNERSHIP COUNTYAGENCY FEDMLAGENCY <br /> CITY NAME STATE ZM CODE -�.. / PHONE It WITH A <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLE ED) ///✓� <br /> NAME OF OWNER ! CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bubbskau INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUKTYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmbYIACW E:l t SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> =5 LMEROFCREDIT ]s ExEMPnoN =0 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.Q U. 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNERSTITLE DATE MONTHIDAYNEALR <br /> LOCAL AGENCY USE ONLY <br /> i <br /> C�a I q JURIS + �o1/I FA 0 <br /> El <br /> OC TON CO E -OP NAL CENSUS TRACTi -OfTWAL allPVISOR-DISTRIOT CODE -OPTIO <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 /> OWNER MUST FILE THIS FORT°WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNn STORAGE TANK REGUUTK)NS <br /> FORM A(3AT3) FCROW]A-P%, <br />