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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 'cao <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR <br /> i •Y/ <br /> COMPLETE THIS FORM TOR EACH F LITYlSITE •�•o. o <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 P MANENTLY <br /> ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT SITE <br /> ❑ B TEMPORARY SITE CLOSURE C� <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) ✓ / <br /> Oda OR FgCILITY NAME <br /> ADDRESS <br /> ��� STATE <br /> CROSS STgEET PARCEL 9(OPTIONAL) <br /> CITY NAME 7/ <br /> �./ STATE ZIP CODE SITE NE WITH OE <br /> CA 5 � r� � X2 . 7 <br /> 701NDIC TE Q CORPoRAnON Q INDIVIDUAL Q PARTNERSHIP <br /> Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q I'MERALAGENCY <br /> TYPE OF dUSINES3 DISTRICTS❑ t GAS STATION 2 DISTRIBUTOq a ✓ IF ATIAN •OF TANKS AT SITE E.P.A. I.0.s <br /> O S FARM O A PROCESSOR Q S OTHER ORTRUSTVLAND S (opfbna) <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> GAYS: NAME(UST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHT$; NAME(LAST.FIRST) <br /> PHONE J WITH AREA CODE NIGHTS: NAME(LAST,FIRSTI <br /> If. PROPERTY OWNER INFORMATION- MUST BECOMPLETED P <br /> NAME <br /> CARE OF ADDRESS INFORMATK7N <br /> MAILING OR STREET ADDRESS <br /> ✓ Qu E V10IGNl Q INDIVDUAL Q LOCAL AGENCY Q <br /> CITY NAME Q CORPORATION J PMTNERSHIP Q STATE AGENCY <br /> COUNrY,AGENCY Q FEDERALAGENCY <br /> STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ApORESS <br /> ✓ ro�n�gc� Q INDIVDUAL Q LOCAL AGENCY Q STATEAGENCY <br /> CITY NAME Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERALAGENCy <br /> STATE LP COO- PHONE 8 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAG FEE ACCOUNT NUMBER-Call(916)323.9555 if questiOns arise. <br /> TY(TK) HO r4-F4 -[=1. 1 <br /> 1. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ Ou avgleaM QI SELF-INSURED Q 2 GUARAMEE <br /> Q SLETTEROFCREOR Q B a(EMPMN Q ] INSURANCE Q A SURE YBOND <br /> Q 99 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 FOA LEGAL NOTIFICATIONS AND SILLNG: <br /> I.❑ IL[D IIL� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CK MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED d Sr-NATURE) <br /> APPLK:ANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COOU7NTTYY R JURISDICTION R <br /> FACILfTYN <br /> LOCATION CODE .DPT 0 l <br /> O CENSUS TRgCT .[ply-NAL SUPVISOR-DISTRIOT CODE .OpipAdL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST <br /> FORMA(SAI) (T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFO TION ONLY. <br /> t�G <br />