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6 • f <br /> STATEOFCAUFORNIA Af f• ' <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT E_] 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT [�] 6 TEMPORARY SITE CLOSURE r' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBq OR FAC I AME <br /> . INEARIEPT <br /> OR <br /> ADDRESS �-+I L�C�r��l V• / <br /> 25aa ST EET, PAACELO(OPTIONAUCITY NAME r l SITE PHONE a WITH AREA LADE <br /> 5 D <br /> TO INDICATE 0 CORPORATION ED INDIVIDUAL 0 PARTNERSHIP -AGENCY 0 COUNTY.AGENCY• 0 STATE-A • <br /> N OOner d UST Is a public agency,farfplete the fo6owbp:name Of Superv4p d DISTRICTS GENCYE:1 FEDERAL-AGENCY' <br /> ONYbn,eectbn,Of 011100 which gteralee the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.0(OpfAanel) <br /> Q 3 FARM Q 4 PROCESSOR MOTHER OOq RESERVATION <br /> TRUST IEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NK9HTa: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATK)N <br /> MAILING OR STREET ADDRESS ✓000bM6kab L-J INDIVIDUAL O LOCAL-AGENCY <br /> O El STATE-AGENCY <br /> CORPORATION <br /> CITY NAME 1:3 PARTNERSNP D COUNfY#GENCV ED FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓b0c blfWces INDIVIDUAL O LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> CITY NAME 0 CORPORATION O PARTNERSHIP O COUMY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - 2 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmwinEkOe 0 1 SELF-INSURED ED 2 GUARANTEE 0 3 INSURANCE <br /> O 5 LETTEROFCREDT O 6 EXEMPTION 0 l SURETY BOND <br /> 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 it.ED III.0 <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(PRINTEDB SIGNED) OWNERS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION a FACILITY# <br /> LOCATION CODE -OPTIONA[ CENSUS TRACTS-ClPagp LqL 9UPVISOR-D13TgM;T C00E-CprpA/gl <br /> 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKNLS//J�- <br />