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STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EAC CILrTYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ D RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENT OSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ N AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> dn <br /> r 's <br /> ADDRESS NEAREST CROSS STRE�ET PARCEL A(OPTIONAU <br /> Co � <br /> CITYNAME / ,TACZIP COOE�� SITE PHONE t WP3sga <br /> TOIN Box Q CORPORATION INDIVIDUAL Q PART"P LOCAL-AGENCY <br /> Po-A ENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEOERALAGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ pV IF INDIIAAN A OF TANKS AT SITE E.P.A. L D.a(PPdwal) <br /> Q AT <br /> 3 FARM Q a PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NgLAE(LAST. IRS)), PHONE 0 WITH AREA COO" DAYS: NAME(LAST,FIRST) <br /> NIGHTS:)/NAME( ,FIRS Ty (WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE•WITH AP-kCOOE- <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Wx 0wdC Q INDIVIDUAL Q LOCALAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CWNrY-AGENCY Q FEDERAL-AGENCY <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 /> MAILING OR STREET ADDRESS ✓ emRiM m Q INDIVIDUAL Q LOCAL-AGENCY Q STAT&AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - a Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm bi-AeAN Q I SELF-INSURED Q 2 GUARANTEE 0� 3/INSURANCE Q A SURETY BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION CLI,*OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo of HI is checked. <br /> CHECK ONE BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Eu R.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUEANTS NAME(PRINTED A SIGNATURE) APPUOANTS TITLE DATE MONTHIOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION 6 FACILITY s <br /> Y <br /> LOCATION CODE -OPTIONAL (CENSUS TRACTayOPT*ML - SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION• FORM 9,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FOR0013A.5 <br /> ��, <br /> J (y� <br />