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• STATEOFCAUFORMA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY � f NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF:INFORMATKDN 7 PERMANENTLY CLO <br /> ONE REM 2 INTERIM PERMIT 3 AMENDED PERMIT <br /> O 6 TEMPORARYURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DM&Aq FACILITY NAME <br /> NAME OF OPERATOfl <br /> A RESS O <br /> 44 NEA STC STgEET p A(gPfDODU <br /> CITY NAME <br /> C� O STATE I ZIP CODE SITE PHONEa WITH AREA CODE <br /> ✓eox CA o�0 <br /> TONDCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LGM-AGENCY Q COUNTY-AeENCY' Q STATE-AGENCY' <br /> N ownAr d UST Is a Public agency,ONTP G the following:name d Supervisor d division,sectbn.DSToRllce aperAee the UST <br /> whIch Q FFDEML-AGEIICY' <br /> TYPE Of BUSINESS Q i GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.A(gdhyg <br /> Q S FARM 0 4 PROCESSOR 6 OTHER ORTRUSTVATIONLANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIR T) PHONE a WITH AREA ,ryTT DAV3:NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> 00 <br /> NK94TS:NAME BAST,FIRST) P A WITH AREA CODE NIGHTS: NAMELAST,FIRST)T) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓60 .mcaM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPDPAT10N Q PARTNERSHIP Q COUNTWIGENCY Q FEDErUL-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 /> MARLIN TR REBS ✓ b 0dbaN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FFDERALAGENCY <br /> CITY N STATE ZIP CODE P ONE A WIT MEA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> �/yp�pyigoy Q 1 SELF-INSURED Q 2 GUARANTEEQ I INSURANCE Q 4 SURETY BOND <br /> Q 5 IETTEROFCREOT Q 6 EXEMPTION ,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: it.O III. <br /> 54 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNEFrSTM-E DATE MCNTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION 0 FACILITY* 5 D o <br /> LOCATIONOODE -OPTIONAL CENSUS TRACT@ -OPTIONAL SUPVISOR-DISTRIOT CODE -OPTIONAL <br /> 3, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THE IS A CHANGE OF SITE INFORMATION Y. I <br /> FORM A(G'B3) O <br /> OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL.A�TIONS � A <br /> , AA <br />