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�✓ STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 a,� e a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A sr _ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE In - <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5.CHANGE OF INFORMATION O T PERMANENTLY CLOSED �) <br /> ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NIEA89 TCROSS, �J PARCELt KIPTIONAL) <br /> CITY NAME STATE GZI ODE l'/`p• SITE PHONE M WITH AREA CODE <br /> CA <br /> ✓BOX O CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY [:1 COUNTY-AGENCY* O STATE-AGENCY* O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> •Noalxol UST'sapubECapmT,mmpMle Nekflmkq lame dsupoMw,d&+ .adioswoffmx chwe2aNe UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> VIFINDIANI#OFTANKSATSITE E.P.A. 1.D.R raptkn 0 <br /> Q 3 FARM Q 4 PROCESSOR O 5 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 N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME r r fv:Te ^; .� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORE S$ G G1 1 boxlo In e , D INDIVIDUAL LOCAL-AGENCY ED STATE- <br /> AGENCY <br /> O CORPORATION E::]PARTNERSHIP ED COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME/ I �„vA 1_ (J`(,J .Q STATE LP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATI N-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS .1bmloiMimle 0 wDIVIOUAL O LOCAL-AGENCY ED STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bov tolMrale I SELF-PI.SURED =2 GUARANTEE 0 3 INSURANCE =4 SURErYBm Q 5 LETTEROFCREDR Q S EXEMPTION �T STATE FUND <br /> O8STATE FUND&CHIEF FINANCIAL OFFICER LETTER OPSTATE FUND&CERTIFICATE OF DEPOSIT OIDLOCAL GOYT.MECHANISM = SBOTHER <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: 1.O IIX III.a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY 5( <br /> COUUNNTTYYY# JURISDICTION# FACILITY# UDa' <br /> 1�JJ <br /> LOCATION C DE -OPTIONAL CENSUS TRACT# -OPT# AL SUPVISOR-DISTRIC DE -OPTIONAL <br /> A <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS o(�1 <br />