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• STATE Of CALIFORNIA • a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AC <br /> COMPLETE THIS FORM FOR EAC ACILRY/SITE <br /> MARK ONLY ❑ T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> SSITE <br /> ONE REM ❑ 2 INTERIM PERMIT O # AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE �1 <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) I <br /> 08A AGILITY NAME NAM FOPERA OR <br /> er hrn Ya?1 l�icvKs <br /> ADDRESS O rn a NEA TCROSS STREET PMCEIM(OPFIONAu <br /> 5/UJ brn h o 0 <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> K CA <br /> I/ BOX <br /> TOINOICATE [1:1 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY D STATE AGENCY <br /> 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR 0RESERV <br /> ✓ IF IATION <br /> NDIAN xOF TANKS T SITE E.P.A. I.D.#(optima <br /> 0 3 FARM Q # PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 8 WITH AREA r.OnF <br /> EHONF#WITH AREA COOP <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAPE OF ADDRESS INFORMATION <br /> MAILING OR STREETAODRESS ✓hoa binokap D INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> D CORPORATION D PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 m1cau O INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-T47- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHODS) USED <br /> ✓boa biNkal# 0 1 SELF-INSURED LV2 GUARANTEE 0 2 INSURANCE 0 A SURETY BOND <br /> O S LETTEROFCREDIT O 6 EXEMPTION 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ [L❑ III ❑ <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® COLI C I i <br /> LOCATION CODE -�7/ONAL (CENSUS TRACTa -OPTIONAL SUPVISOR-DS;RICT 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 /> FORM A(5.91) Qqq <br /> FOR0012A5 <br />