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a <br /> STATE OF CALIFRCES RNIA <br /> CONLl� <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM F-1 2 INTERIM PERMIT E::] d AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA IL N NAME OF OPERATOR <br /> v <br /> ADDRESS �/t I_ NUKST CRO$S�STREET PARCEL#(OPTIONAL) <br /> 1401 V. <br /> CITY NAME STI/C/COA//YLQ•Y/ZwFIP ,. w� SITE PHONE#WITH AREA CODE <br /> ✓ Box <br /> TOINDCATE O CORPORATION INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY COUNTY.AGENCY' STATE-AGENCY' =FEDDML-AGENCY' <br /> DISTRICTS' <br /> 'N owner of UST is a public agency,mnplete the following:name of Supervisor ot dielebn,section,or oaiw which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#iciotb e <br /> RESERVATION /r <br /> Q 3 FARM Q A PROCESSOR = 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(VST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boebltNbeN [::] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL#GENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bbdk## INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION E71 PARTNERSHIP COUNrY-AGENCY Q FFDEPAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#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 W- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> �/boebyy O 1 SELF-INSURED O UARANTEE O D INSURANCE O A SURETY BOND <br /> S LETTEROFCREDT OVF6 EXEMPTION D aB 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.O I.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTHDAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILfTY# ^ <br /> f ISlf /y,T /y <br /> LOCATION C D -OPTIONAL <br /> L CENSUS TRACT# -OPTIONA 9UPVISOR-DSTRICT CODE -OP <br /> ?�- () <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THI6 IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) j 1`00003 P <br />