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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOO EACH FACILITYISITE <br /> MARK ONLY f NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOB <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT E:1 6 TEMPORARY SITE CLOSURE �ll <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILTYNAME ,o/V NAMEOFOPERATOaOR <br /> ADDRESS/I/�V UU NEA Es CRYO STREET PARCEL#'(OPTIONAL) <br /> .� er <br /> CITY NA E STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> /11 <br /> ✓ x <br /> A <br /> C <br /> TOINOICIITE O CORPORATION INDIVIDUAL O PARTNERSHIP LOCALAGSENCY ED COUNTY-AGENCY' O SrATE-AGENCY' E-3 FEDERAL-AGENCY' <br /> DISTRICT - <br /> N owner d UST Is apublic agency,complete the following:narne of Supervkor of dNkbn,section,or IN ice which operates the UST <br /> TYPE OF BUSINESS 0 ) GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN I#OFTANKSATSITE E.P.A. I.D.•(optlmal) <br /> O 3 FARM Q 4 PROCESSOR 5 OTHERO RESERVATION <br /> OR r <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYSyNAME(LA T,FIRST) PHONE%WITH AREA CODE DAP: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 3 3111 NIGHTS: NAME( T,FIRST) PHONE a WI Aq A CODE NIGHTS: NAME(LAST,FI ST)_ <br /> PHONE i WITH AREA CODE <br /> a I D �} <br /> 11. PROPE TY OWNER INFORMATION- MUST BE COMPLETED <br /> NA IJ _YL, <br /> � CARE FA DRESS INFOAMATI N <br /> (/ /Y v Jvil <br /> MAILING OR STREET ADDRESS ✓ b Mkab t INDIVIDUAL• Q LOCAL ST -AGENCY <br /> CI ME t O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> T TE ZIP COD <br /> c acs SPHONE a WITH AREA CODE�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S Q/ate <br /> MAILING OR STREET ADDRESS ✓box 0indic Q INDIVIDUAL O LOCAL AGENCY <br /> STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY I= FEDERAL-AGENCY <br /> CITU NAME 7E_7 <br /> CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4 - a a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ babindiate 0 1 SELF-INSURED Q 2 GUARANTEE ED 3 INSURANCE <br /> D 5 LETTEROFCREDIT 0 6 EXEMPTION OTHER ]1 SURETYBOND <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.❑ II.❑ 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 B SIGNED) OWNER'S TITLE DATE MOfNTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION 1I <br /> FACILITY IF <br /> LOCATION CODE -OPTIONAL CENSUS TgACTi -OPTIONAL 9 -g37'RICT CODE•OPTIONAL <br /> D 3 gWtY <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) OWNER MUST FILE THIS Fir THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />