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STATE OFCAUFORWASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A r <br /> :vim, ea <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY � t NEW PERMIT °'�nonr' <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O <br /> ONE REM Q 2 INTERIM PERMIT 7 PERMANENTLY CLOSED 9 <br /> 0 6 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ADORE F CILITV NAMF 1)n/ <br /> � NAM ERATO <br /> ADORE 1)4 <br /> 1/� p <br /> CITY Na-� I ✓"'(./ NEARES RO REET PARCEL a(OPTIONAL) <br /> STATE ZIP DE <br /> .1 BOX CA SITE PHONE a WITH AREA CODE <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY <br /> If OwnPEO of UST Is a public agency,complete the/allovAn4:name a1 SUPBIVISOT of division,section,DISTRIICTT whkh 0 COUNTY AGENCY• 0 SATE-AGENCY, ED FEDERAL-AGENCYOr Office ' <br /> TYPE OF BUSINESS O t G/15 STATIONO 2 DISTRIBUTOR Obstinate the UST <br /> ✓ IF INDIAN a OF TANAT SITE E.P.A. I.D,a(Mlkvrell <br /> E:] 3 FARM O 4 PROCESSOR RESERVATION <br /> 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMA <br /> CODE <br /> ) <br /> DAYS: NAME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> PHONE a WITH A <br /> DAYS:NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRS PHONE 8WI7H AREA CODE <br /> T) PHONEa WITH AREA <br /> II. PROPERTY OWNER INFOCODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE <br /> NAME RMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓bmbindbats 0 INDIVIDUAL 0 LOCALdGENCY <br /> CITY NAME 0 CORPORATION 0 PARTNERSHIP 0 STATE-AGENCY <br /> 0 FEDERAL-AGENCYSTATE-AGENCY <br /> ENCY <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 ADDRESS —.—_ <br /> ✓box Dindicate O INDIVIDUAL <br /> CITY NAME 0 CORPORATION 0 LOCAL-AGENCY (]STATE-AGENCY <br /> -- 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FTATE-A <br /> 9TATE ZIP CODE <br /> PHONE a WITH AREA CODE AGENCY <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 2 2 <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED) <br /> ✓hm —IDENTIFY THE METHOD(S) USED <br /> binds ate 0 i SELF-INSURED 0 GGUARANTEE <br /> D 5 LETTEROFCRED'T D 8 E%EMPRON 0 3 INSURANCE L_j 4 SURETYBOND <br /> 0 9B OTHEq <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 /> 1. <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYIWOKLEDCE,IS TRUE AND CORRECT <br /> II <br /> OWNEq'3 NAME(PgINTED 8 SIGNED) <br /> OWNERS TITLE <br /> DATE MONTWDAY/VEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY <br /> gr <br /> T <br /> — JURISDK:TION# <br /> ff FET-1 /////T/y�/, FACILITYY## <br /> LOCATION CODE - TIONAL CENSUS TRACT a -OPT�p L� ' " <br /> 90 SUPVISOR-DISTRICT CODE •Op7ADNAL / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERRWr APPLICATION- RMB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(343) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATfONS <br /> 0 0 <br /> FORJWMA7 <br />