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fE YNRR <br /> STATE OF CAUFORNIA <br /> o <br /> STATE WATER RESOURCES CONTROL BOARD W•4g ' „b <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT � CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERAT R <br /> 0/11,0,.",0, 00,11, f <br /> ADDRESS V NEA STCROSS TREET PARCEL#(OPTIONAL) <br /> -.114W <br /> .1/ / c S _ <br /> CITY NAME `STATE ZIP COQESITE PHONE it WITH AREA ry4 ODE <br /> ul <br /> CA <br /> ✓ BOX CORPORATION 0 INDIVIDUAL 7] PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.0(optional) <br /> IF <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY - NAME(LAS-,;,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> cef-9Y - &// <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA COOS NIGWT5: AME(LAST,FIRST) PHONE#WITH AREA <br /> /CODE <br /> /' <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C` /-C of doYl <br /> MAILING OR STREET ADDRESS /_ ,4.5-t- ✓ box binde INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> St7 y r ORPORATIGN PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ��. STA ZIP CODE PHONE A WITH AREA CODE <br /> �r 511 C _C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `O7--3G;'�43 <br /> NAME OF QWNER / CARE OF ADDRESS INFORMATION <br /> ss-j <br /> MAILING OR STREET ADDRESS (,�j ✓ bx loindic� INDIVIDUAL 0 LOCAL-AGENCY CJ STATE-AGENCY <br /> r r. ORPORATION E71 PARTNERSHIP a COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME – STA ZIP CODE PHONE 9 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. sf 77_34'413 <br /> TY(TK) HQ 4 4- -I d <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box lo indicate O 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT E]Ii EXEMPTION E-1 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ll is checked. <br /> FHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.[—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S ME(PRINTED&[G ED) OWNER'S TITLE 'DATE MONTWDAYNEAR <br /> L6aL A ENCY USE ONLY <br /> COU�NTYI# JURISDICTION# FACILITY# 3 <br /> W <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPnONAL <br /> THIS FORM MIDST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHMiGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM <br /> FORM A(3193) fV�nl FORo033M11 <br />