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• STATE OF CALIFORNIA • -^^`fig •.o of <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A °�� �° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE _ z 'ro <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS 1 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 9 <br /> CITY NAME STATEA ZIP CODE 0,SITE PHONE It WITH EA CODE <br /> 47 <br /> ✓BOX CORPORATION O INDIVIDUAL PARTNERSHIP a LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #ownerof USTis a pubic agency,ccreglete the formwil;nares of swervaorcf division,legion or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ V'IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ❑ 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST IR T) PHONE#WITH A EA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> >zc <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Acf—,-F(G GaA oozw v <br /> MAIUNGOR STREET ADDRE S ✓ box to ndcale # INDIVIDUAL C:1 LOCAL-AGENCY O STATE-AGENCY <br /> V /J✓ CORPORATION O PARTNERSHIP EDCOUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE# ITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> MAILING 0!j STREET ADDRESS�. ✓ boxto ihdiale 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> v - /J#-/\ [11 CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PONE#WITH AREA C DE <br /> 9jfZLf <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- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to micale I SELF-INSURED =2 GUARANTEE =3 INSURANCE =a SURETY BOND O 5 LETTEROFCREDIT = 6 EXEMPTION =7 STATE RIND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O#STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = N 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.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'SnTLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COLINTY# JURISDICTION <br /> Mt� T—W k FACILITY o00541� /, <br /> �O <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z ID 8 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6 95) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRf STORAGE TANK REGULATIONS <br />