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STATEOFCAUFORMA <br /> "AT'WATER RESOURCES CONTROL BOAFID <br /> J UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA ' <br /> 3 <br /> COMPLETE THIS FORM FOR EACH FACILTTYlSITE �MARK ONLY ❑ 1 NEW PERMIT <br /> ONE REM ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION <br /> ❑ 2 INTERIM PERMIT [:714 AMENDED PERMIT PERMANENTLY LOBED SITE <br /> 8 TEMPORARY g1TE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYN E <br /> m 4 <br /> _RR CC fAMEOF bh / <br /> 3S •! <br /> NEARE CROSS STR p <br /> CITY NAM t )cTl <br /> C� BTATE ZIP CODE SITE <br /> BOX PHONE/WITH AREA CODE <br /> ✓ <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY <br /> If owner W UST Is a pubic agency,Wf .the I011owinB:name of Supervior of dNkbn,6BCIbn,Dpr RICT WhichO CWMY-AGENCY' Q STATEAGOICY' Q FEDERµ-AGENCY' <br /> TYPE OF BUSINESS GHics ow l,the UST <br /> I GAS STATION ❑ 2 DleTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D,a A3oNaw# <br /> 3 FARM Q 4 PROCESSOR Q 6 OTHER O RESERVATION <br /> 11�1OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONOAR <br /> DAYS: NAME(LAST,FIRSTPHONE a WITH AREA CODE Y) DPBOnaI <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGFIT3: NAME(LAST,FIRST) PHONE Is WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ANG�RIJJRE <br /> — <br /> CARE OF ADDRESS INFORMgTION <br /> AODR S ✓bar bW&aimINDIVOUAL l� LOCA4AGFNCVQ STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERALAGENCY <br /> STATE ZIPQDi P NE a WI H A CODE <br /> 1:3 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) V <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bUblydlcale <br /> Q INDIVIDUAL L:1LOCAL-AGENCYOSTATE-AGENCY <br /> CITY NAME Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY <br /> 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 r4T4_+ 2 VS <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bwbNltlkale Q I SELF-INSURED Q UARANTEE Q 3 INSURANCE <br /> Q{SURETY SONO <br /> =6 LETTER OFCflEGT EXEMPTION Q B9 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: 1.O II.O 116❑ <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&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 0 JURISDICTION II FACILITY• <br /> 3a PRz31 <br /> LOCATION CODE -OPTIONAL CENSUS TRACU -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERW APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE NPORYATK111 ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA <br /> FORMA(3831 iO110D73AAT <br /> `"` 9� <br />