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• y <br /> STAT10FCALIFORNeA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> .� 1L UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONX 7 PERMANENTLY CLOSED <br /> ONE ITEM Q 2 INTERIM PERMIT s AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) LiaL <br /> DBA OR AGILITY NAME rS. NAME OF OPERATOR <br /> ADDR SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> r <br /> 7 -116 <br /> 6 - <br /> CINAM <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ Bax <br /> CA <br /> TOINDICATE CORPORATION 0 INDIVIDUAL F-1 PARTNERSHIP [] LOCAL-AGENCY COUNTY-AGENCY, [] STATE•AGENCY' FEDERAL-AGENCY' <br /> If owner of UST Is a Public g. DISTRICTS' <br /> p agency,complete the following:name of Supervisor of division,section,or alfice which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATtON = 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. 1-D.#(optima!) <br /> Q 3 FARM 4 PROCESSOR5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> D NAM (LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> nsoyz/ 11 <br /> NIGHTS: NAME(LAST,F1R PHONE#WITH AREA COME NIGHTS: NAME{LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box p Indkale INDIVIDUAL E71 LOCAL-AGENCY 0 STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP = COUNTY-AGENCY = 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 q indicate INDIVIDUAL = LOCAL-AGENCY = STATE-AGENCY <br /> DCORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY = 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 /> ✓bpxtoindicate 1 SELF-INSURED =2 GUARANTEE ❑ 3 INSURANCE <br /> 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =6 EXEMPTION © ss 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 WILLING: <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 b SIGNED) OWNER'S TITLE DATE MONTWlDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION1�5UPVISOR- <br /> FACILITY# <br /> ,. <br /> ELAqM <br /> LOCATION CODE -OPT10 L ICENSUST ACT T! L# -OPSTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �� f Jl_ le <br /> 93 478 FOR=M-R7 <br />