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NIA <br /> G STATE OF ON ` <br /> STATE WATER RESOURCES <br /> flCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME . / NAME OF OPERATOR <br /> �, LP <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTONAU <br /> CI AM STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> ✓ BOX CORPORATION r9 INDIVIDUAL I�PARTNERSHIP LOCAL-AGENCY CDUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TOINDICATE <br /> DSTPoCTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of dNiabn,section,cr office which operafes the UST <br /> TYPE OF BUSINESS 1 GAS STATION E—] 2 DISTRIBUTOR RESEgypTDION # TANK3 AT SITE E.P.A. I.D.#(npl/maQ <br /> Q 3 FARM 0 4 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) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> - Z-0, i <br /> MAILING OR STREET ADDRESS ✓ boxbindPale INDIVIDUAL E:j LOCAL-AGENCY O STATE AGENCY <br /> �L E::]CORPORATION 1E PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NA <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> v �_ s<— <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A Nt$ j <br /> MAILING OR STREET ADDRESS ✓hob WbW 0 INDIVIDUAL O LOCAL AGETICY STATEAGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q 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 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box lnN&ate Q 1 SELF INSURED =2 GUARANTEE L-3 3 INSURANCE 0 A SURETY BOND <br /> D 5 LETTER OF CREDIT =S ExEMpTION 0 go 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.D I.[>I 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 5 SIGNED) OWNER'S TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033AR7 <br /> • • <br /> 1 <br />