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STATEOFCALIFORMA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM ACOMPLETE THIS FORM FOR EACH FA rrYISRE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 6 ADDRESS•(MUST BE COMPLETED) <br /> OBAOR ACILI N p NAME OF OPERATOR <br /> cry <br /> ADD S NEAREST CROSS STREET PARCEL#(OPTINAL) <br /> 641 <br /> CITY NAMEy� STATE ZIP COW SITE PHONE a WITH AREA CODE <br /> 7 CA <br /> BOX <br /> TO INDICATE O RATION 0 INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY O ODUNTY-AGENCY' O STATE-AGENCY' I=)FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'H owner of UST is a public agency.oonplete the following:name of Supervisor of oNlsbn,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR / <br /> IF INDIAN <br /> #OF TANKS AT SIT E.P.A I.D.#Iopllmel) <br /> ❑ ATION <br /> 3 FARM ❑ 4 PROCESSOR ❑ S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eoabindbate 0 INDIVIDUAL Q LOCAL-AGENCY D STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP COUNrYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TWOWINER INFORMATION-(MUST BE COMPLETED) <br /> NAM RCARE OF ADDRESS INFORMATION <br /> AILING OR STREET AD R SS S/_V, babow INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> �(, , CORPORATION O PARTNERSHIP L]COUNtY4AENCY Q FEDERAL-AGENCY <br /> CITY NAME 17TE ZIP CODE PHONE#WITH AREA CODE <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCO UMBER•Call(916)322-9669 if questions arise. <br /> TY(T 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Iba 1c Micas, � I SELF-INSURED O 2 GUARANTEE D 3 INSURANDE 4 BOND <br /> D 5 LMEROFCAE01T O e EXEMPTION Q gP OTHE <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the taWowner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY f OGE,IS TRUE AND CORREC <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTH(DAYNEAR <br /> LOCAL AGENCY USE ONLY JZ <br /> COUNTY# JURISDICTION# FACILITY <br /> ' f <br /> W <br /> 15V 6i2l /l <br /> LOCATION CODE-OPTIOW, <br /> CENSUS TRACT - SUPVISO DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST St ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, GE OF SITE INFORMATION ONLY. <br /> FORM A(3'93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKjN$, <br /> FaRBE33Am <br /> � ������ <br />