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0 ! <br /> STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH 1`40LITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT E24 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OPOPERATOR <br /> ADDRESS NE §TCRJOj� T E _ PARCEL#(OPrgNAL) <br /> G ✓ VY, J h-r� <br /> CITY NAME STATE ZIP nobir SITE PHONE WITH AREA CODE <br /> CABox <br /> TO INDICATE COflPORATION INDIVIDUAL 0 PARTNERSHIP 0 DISTRICTS, Q COUNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> Y' <br /> d UST Is a public agency,oonplae the IOAowing:name d Superviaer d dNlebn,seNbn,cr office Which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.t(opbnal) <br /> OR <br /> 0 3 FARM Q 4 PROCESSOR 0 6 OTHER ❑ RESERVATION <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hmbindluM 0INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY I�FEDERAL-AGENCY <br /> CITU NAME 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 ✓ boabindbaM [=1 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION I=1 PARTNERSHIP Q COUNTY-AGENCY 0 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bhMbau, L-1 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE l�4 SURETYBONO <br /> O S LETTEROFCREDIT O 6 EXEMPTION go OTHEfl <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: I.[�j 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 NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHrDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACTA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTpNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SrrE INFORMATION ONLY. <br /> FORMA(3,83) KNIS <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAT <br /> FOROVJ3AA7 <br />