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• `iOVll f <br /> r t• <br /> r <br /> STATE OFCAUFORNIA ;� o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 1 / UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A 3 <br /> YCOMPLETE THIS FORM FOR EACH FACILN'YISITE �•`"°""� <br /> MARK ONLY F-11 NEW PERMIT F—] 3 RENEWAL PERMIT [_15 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT ❑ e TEMPORARY 517E CLOSURE 5E <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OPERATOR A e- <br /> /J F,�. <br /> OBAO CILITV NAME �- I_ ,.� (J/ O�/1 C.�(�/ <br /> AODRE RES�CHOBS TREET PARI(OPTIONAL) <br /> '32 /t/av ✓ % l <br /> CITY NAM STATE ZIP E, 2 /T SITE PHONE a WITH AREA CODE <br /> CA <br /> '/ BOX Q CORPORATION C1 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> N owner d UST Is a public agency,wmplde the following:name of Supervisor d tlNk .s 10 or o5ice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEflVA0TI0N %�TANKSn /E E.P.A. 1. -*(0001190 <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER ORTRUSTLANDS _( <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST�BE COMPLETED CARE OF ADDRESS INFORMATION <br /> —77; <br /> AME <br /> MAILING OR STREET ADDRESS ✓ cox biMkaN O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> f CORPORATION O PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bInd"a = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP E71 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA 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 COMPL D)—IDENTIFY THE METHOD(S) USED <br /> ✓by bintlkaU I SELF-INSURED 2 ARANTEE Q 3 INSURANCE L_j d SURETY BOND <br /> 5 LETTER OF CREOT EVS EXEMPTION Sg 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ I.❑ 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 NAME(PRINTED&S IGNED) OWNER'STITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ^/n'y�� <br /> 259 <br /> LOCATION CODE -OPT CENSUS TRACT# -Q'TI SUPVISO - TRIG -OPT10NAL (_(/ �(/ <br /> U Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA FORDmWR7 <br /> FOAM A(393) / C' ��• • <br />