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.. w� STATEOFCALIFORMA a <br /> STATE WATER RESOURCES CONTROL BOARDtv/fUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT D 3 RENEWAL PERMIT6 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE REM I] 2 INTERIM PERMIT Q A AMENDED PERMIT IJ TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACILITY NAME NAME OF OPERATOR <br /> C' <br /> ADDRESS NEAflEbY CROSSSTREET PARCELa(OPrIONAL) <br /> g C� �[GfJJ'G� <br /> CITY NAME STATE ZI 917E PHON aWRH AREA CODE <br /> CAaoY - 7 <br /> I/ Box <br /> TOINDICATE Q CORPORATION Q INUMAL Q PARTNERSHP Q LOCAL-AGENCY Q COUNTYAGENCY' Q STATE AGENCY' Q FEDEMLAGENCY' <br /> DISTRICTS' <br /> 'N or of UST Is a public agency,mrrpleta the tolowing:name Of Supowlsor of division,section,or oaim which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION I] 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.Jr(gximae <br /> 3 FARM a PROCESSOR 6 OTHER RESERVATION <br /> L7 Q OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME ST,FIRST) 'V PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH EA CODE <br /> iewn <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITHAREA CODE NIGHTS: NAME BAST,FIRST) OPHONES WITH AREA CODE <br /> jl 1 <br /> p II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED Pro <br /> o 6vL <br /> p/ NAME ` CARE OF KESS INF MATK)N <br /> MAILING OR STREET ADDRESS ✓ bw bintlhaY Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> (�. Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDEPALAGENCY <br /> o <br /> CITY ME 9T lE ZIP ^D� PtIONE a VqTH AREA CODE <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) C d <br /> NAME OF OWNER e,so CARE OF ADDRESS INFORMATION <br /> �'r <br /> MAILING OR ST ET ADDRESS- v' le box btmfik Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> `y7 Q CORPORATION Q PARTNERSHIP Q CWNTYAGENCY Q FEDEIULAMNCY <br /> CITY NU STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> bNAkNe O 1 SELF INSURED O2 GUARANTEE O 3 INSURANCE Q4 SURETY BOND <br /> .1 box <br /> 0 6 IETTEROFCREDIT 0 6 EXEMPTION Q 99 OTHER A;o 1'U E <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 BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E-1 II. AILD <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S TRLE DATE MONTHIWY/VEAR <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a <br /> JURISDICTION• F 1\ <br /> � b <br /> LOCATION CODE -OPTIONAL CENSUS TRACTI -OPTIONAL SUPVISOR-DIST_ E -OPT*AAL <br /> NAL - <br /> C <br /> THIS R MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORoao6Am <br /> FORM A(SATS) <br /> Add Si /,,_ 4' o"+ T&n)k ?O 1 N✓P�►1 . <br />