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xea a CO1i <br /> n- FN{-e STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD W db o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA as - , .i� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENRY C <br /> MARK ONLY UU^^ <br /> F� <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA �ACILI'/YONAME57 —State <br /> , ^ - - _ n <br /> NA QE�OP�.�ATQr� 4 / PA y <br /> V (.,Tti EI'T�,I[L'"AD.,.x N(EA,r UT•RR?OSS rIRE 4ax/LKI.`T/ .e PA XWIOPTI�ON'AL) <br /> ADORE$$/ ^ �O T <br /> ✓•( OJT I ' <br /> STATE ZIP D I E PhhH # TIy./A�.Rj CO <br /> CITY NAM CA T k a 1) I J <br /> ✓Box CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 � <br /> DISTRICTS <br /> NCY 0 COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> D <br /> TO INDICATE <br /> 'Mowneral USTbe Wbtic agenry,compNla the folbwng named supervisorddHision,section oro#uw which opereles the UST ✓IF INDIAN #OFTAN?SATSITE EP.A. I.D.#(cpfianeQ <br /> TYPE OF BUSINESS O t GAS STATION Q 3 DISTRIBUTOR O RESERVATION 1 <br /> 0 3 FARM Q 4 PROCESSOR Q 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 /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME y� I- / <br /> IY- IU\' ���T g� �L�+ -ter ✓ xlo hdrale 0 INDIVIDUAL 0LOCAL-AGENCY 0 STATE-AGENCY <br /> VUU yW OR STr/I �E , A 0 / / RPORATION 0 PARTNERSHIP 0 COUN <br /> TY-A <br /> ONE1LGENCY!��{ 0 FEDERAL-AGENCY <br /> ITYN/V\ IL.�r�)yH'• +^I,{r/yI /r/rJr/,, ! ST�.T�•-(^" ZIP , I `A O POO• Ia I D DI ( �� <br /> CITY NpdE�r 1 �/ T �.�j r (✓(i It " <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) CARE OF—ADDRESS INFORMATION <br /> ENAMEOF OWNER ✓ boxtoindaxe 0 INDIVIDUAL 0 LOCAUAGENCY 0 STATE-AGENCY <br /> G OR STREET ADDRESS <br /> 0 CORPORATION O PARTNERSHIP =COUNTY-AGENCY O FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ F4—F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> SELFJNSVPED O 2 GUARANTEE O 3INSURANCE 0 4 SURETY BOND D 55 LETFER$1F CREDIT O B EXEMPTION O]STATE FUND <br /> D8STATEFUND&CHIEFFINANCIALOFFICER LETTER O9 STATE FUND CERTIFICATE OF r III LOCAL GOVT.MECHANISM 099 OTHER <br /> ✓box to iiMicate <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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) <br /> TANK OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY e C S <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> SUPVISOR•DISTRICT CODE pp Jp#IAL <br /> LOCATION CO •0PjIONAL CENSUSTTGCTi#�' AL ,V"�/V�o UY <br /> THIS FORM MUST BE ACCOMPANIED BY AATT_!LLEAAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORrrr�THE LOCAL AGENCY THE UNDERGRO�STORAGE TANK REGULATIONS <br /> FORMA(695) I V Oy1p�u6' <br />