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i <br /> ! STATE OF CALIFORNIA = + <br /> STATE WATER RESOURCES CONTROL BOARD ;®�' - .v S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA 'e+ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE - <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT m 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 5 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OSA OR FACILITY NAME NAME OF OPERATOR <br /> QN <br /> A DRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> ) S7 <br /> SITE PHONE#WITH AREA CODE <br /> CITY NAME STATE ZIP CODE <br /> CA <br /> TOIN BOX D CORPORATION O INDIVIDUAL 0 PARTNERSHIP O DISTRICTS D COUNMAGENCY O STATE-AGENCY I�FEDERAL-AGENCY <br /> 2 DISTRIBUTOR O ./ IF INDIAN #OF TANKS T SITE E.P.A. I.D.#(optional) <br /> TYPE OF BUSINESS 1 GAS STATION <br /> ❑ ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 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) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> A.EA Cor <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ` - ' A CARE OF ADDRESS INFORMATION <br /> L L7 0 <br /> MAILING OR STREET ADORES ✓f i 1)(11110 11,41c,111, (] INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> ��� w 1- 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME N STATE ZIP CODE PHONE#WITH AREA CODE <br /> E{,a, ' CA <br /> 9SzoS� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa 0Indbax, 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4141- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa b Indic" 0 I SELF INSURED 0�GUARANTEE l�31NSURANCE 01 SURETY BOND <br /> 0 5 LETTER OF CREDIT LLa 1 EXEMPTION 0 91 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.e III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PH INTER&SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> z7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTONAL SUPVISOR-DISTRICT CORE -OPTIONAL <br /> GO(EL Sf 231fio 3 f125- 1 C44 <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(5-91) FOROW3A 55 T <br /> �� f 0\�v <br />