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060JM C <br /> C <br /> STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,s <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'"•��"`� <br /> MARK ONLY F__j 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION v <br /> 7 PERMANENTLY CLOSED <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT E�j 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> MRI NAMEOFOPERATOR/r NE E TCROSS STR TPAiiCEL11(OPfKINAU <br /> V � ✓ST CA 521` <br /> ^ ` / SITE PHONE s WITH AREA CODE <br /> ✓ BOX LOCAL-AGENCY AGENCY K//� <br /> TOINDICATE D CORPORATION Q INDIVIDUAL O PARTNERSHIP 0 DISTRICTS' CAUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> If owner d UST Is a public agency,complete the following:name of Supervisor of divisbn,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN IN OF TSITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE S 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 /> MAILING OR STREET ADDRESS ✓ box lolrdkale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE Al WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bin icaa [:1 INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION M PARTNERSHIP COUNTY-AGENCY E=j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION <br /> NUUST <br /> �STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO R 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkats = 1 SELF-INSUREDl� GUARANTEE Ij 3INSURANCE Ij 4 SURETY BOND <br /> =5 LETTER OF CREDIT 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: 1.0 II.= 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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY JZP 231a.5(o <br /> COUNTY# JURISDICTION# FACILrrY# .37.37 - <br /> 3 Piz ® I)-79-q-3 <br /> LOCATION CODE -OQTIO L CENSUS TRACTS7—:3 TI0 SUPVISOft�DISTRIC OPt 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)6ORR(MO,RE PERMIT APPLICATION- FORM B,UNLES THIS 1S A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) � FOR0033AJi7 " <br /> 0 <br />