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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED SITg_ <br /> ONE REM F--j 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> )DBA R ACI E %. NAME OF R <br /> ADD SD � NS SS ETRE P ELaIOPrxNIW <br /> CITY NA:5 STATE SITE PHONE a WITH AREA CODE <br /> J CABox <br /> 503 <br /> TO INDICATE 0 CORPORATION E:D INDIVIDUAL O PARTNERSHIP O DLOGCTANL-CATGSE3N,'Y =1couKrY-AGENCY• O STATE-AGENCY' O FEDERAL-AGENCY' <br /> •H owner of UST Is a public agency.complete the following:name of Supervisor of division,section.or oNiw which operates the UST <br /> TYPE OF BUSINESS F--j I GAS STATION 0 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN a OF TANNJ($AT SITE E.P.A. I.D.a(apfimWJ <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS (%/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hos bYdcMe O INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Cl CORPORATION O PARTNERSHIP O COUNTYUIENCY O FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREETADDRESS ✓ EosbindiceM INDIVIOUAL LOCAL-AGENCY 0STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bb9uN 0 1SELF-INSURED O 2 GUARANTEE 0 a INSURANCE 0 4 SURETY BOND <br /> 5 LETTEROFCREDIT O 6 EXEMPTION =99 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.Q III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNERSTITLE DATE MONTWDAYNEAfl <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrFY <br /> pp, <br /> LOCATION CODE -08r CENSUS TRAC 95 <br /> PVISOR-DISTRICT CODE -OP ; <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 /> FORM A(3093) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND SJ NISTORAGE TANK REGUTATKL 1 <br /> FGfIdG1MA' <br />