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p <br /> t� STATE OF CAUFOPAA <br /> STATE W ATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMA oFY <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> O 1 O PERMIT <br /> 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> NEW PERMIT 3 RENEWALSED <br /> MARK ONLY 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> ONE REM O 2 INTERIM PERMIT 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BECOMPLETED) <br /> OBA0 CILITY NAME <br /> NEAREST CROSS STRE T PMCEU IOPTIONAU <br /> ADDRESS S ' e „y n } <br /> W�� STATE ZIP DE ITE PHONE i WITH AREA CODE <br /> CIN N ME CA O 3- r <br /> �7 <br /> Box CORPORATION INDIVIDUAL PAIITNFASMP I] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' <br /> TOIN Box DISTRICTS' <br /> •N owner d UST la a pu w agency,mnplere the following:name of Supervbor of C'wobn,eeclbn,or o6ice which operates the UST <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR O I/ IF INDIAN i OF TANKS�T SITE E.P.A. I.D.i(apliarMl) <br /> 0 RESERVATION �—�'/lJ <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•W10174W <br /> O S: NAME(L ST,FIRST) ,l P ONEiV,74EA ODE_ AYNA E(LAST.FIRST) PHONE N WITH AREA CODE <br /> L ) <br /> NIGHTS: NAME(LAST, ST) HONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITHABEA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX10I11OIwle O INDIVIDUAL O LOCAL-AGENCY ]STATE AGENCY <br /> CORPORATION O PARTNERSHIP ] COUNTY AGENCY Q FMEMLAGENCY <br /> CITY NAME STATE7 ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ aoa biMbate ] INDIVIDUAL O LOCALAGENCY ]STATE#GENCY <br /> CORPORATION O PARTNERSHIP COUNTY AGENCY FEDEML#GENCY <br /> CITY NAME STATE 77IPCODE7 PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- -n�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eoa biMkaie I SELF INSURED I]2 GUARANTEE 3 INSURANCE ]4 SURETY BOND <br /> 5 LETTER OF CREDIT I]6 EXEMPTION OTHEq _ <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: L II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE R'S NAME(PRINTED S S IGNE D) OWNER'S TITLE DATE MONTHIDAV/YEAR <br /> LOCAL AGENCY USE ONLY ec- T C <br /> C�OODUNTTYY# JURISDICTION# FACILITY t <br /> emsl <br /> LOCATION FE/OPTIONAL CENSU3TMCTi -OPT L 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(3A13) OWNER MUST FRE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIS <br /> 3- ?_ PoRg461M, <br />