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STATE OF CAUFORMA J <br /> STATE WATER RESOURCES CONTROL BOARD W„� 201 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE °ai.c•a�^ <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION7 PERMANENTLY CLOSED 31 <br /> ONE <br /> IT Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT E] & TEMPORARY SITE CLOSURE IV <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> �'� n #-2 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAW <br /> CITY NAME ST TEZIPQ3 CODE ITE PHONE#WITH AREA CODE <br /> 2tX) �jyy-85SZ <br /> ✓ <br /> BOX CA <br /> TOINgCATE O CORPORATION ED INDIVIDUAL O PARTNERSHIP OCAUAGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL AGENCY' <br /> DISTRICTS' <br /> ' <br /> It owner of UST is a public agency,complete the following:name of Supervisor of tlWkbn,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 OAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplranel) <br /> flESERVATION o <br /> Q 3 FARM Q d PROCESSOR E;�1*55_0—_ER 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#WITH AREA CODE <br /> 7] <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHAREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CO DE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSTD /J I/ box blrgkeb [:1 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 6W •/'/ p gdrfo =CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME L G / STATE± ZIP CODE O �- PHONE It AREA CODE <br /> 7� G ry <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmbindkae INDIVIDUAL LOCAL AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP Il COUNTY-AGENCY L-1 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 M44- - 1-5174 7l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ <br /> box 101 0 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDITTION E] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E 11. 111.❑ <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 MONTHADAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION x FACILITY IT <br /> 3 ! Z s :;1,411 <br /> LOCATION CODE -OPTIONAL CENSUSTRBDT}.-- yAL 9UPVISO DI8 ICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE RE PERMIT APPLICATION- FOR MA3,UNLESS THIS 1S A CHANGE OF SITES INFORMATION ONLY. <br /> FORMA(3W) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOflONJAR/ <br />