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c6oUR C <br /> STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> i <br /> s MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ZHL <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA ILkTY NAME NAME OF OPERATOR <br /> ADDRESS NEAPEST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE FSITE PHONE#WITH AREA CODE <br /> CA ;7 9) 77 h—BOX <br /> � <br /> T NDICATE CORPORATION INDIVIDUAL ® PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCYFEDERAL-AGENCY' <br /> DISTRICTS' <br /> '11 owner of UST Is a public agency,complete the fallowing:name of Supervisor of division,seclion,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESEIF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(goriorrafp <br /> AT <br /> 3 FARM 0 4 PROCESSOR � 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( T.FIRST) PHONE#WITH AREA 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 /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> )- ./. tom, r! �"�r�, i <br /> MAILING OR STREET ADDRESS ✓ box loIndicate ED INDIVIDUAL 0 LOCAL•AGENCY STATE-AGENCY <br /> r� -d 7r LL 0 CORPORATION = PARTNERSHIP 0 COUNIY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> — _ I <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSf ✓ box to indicate INDIVIDUAL [] LOCAL-AGENCY STATE-AGENCY <br /> L G CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AG€NCY <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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box lo indicate [__1 I SELF-INSURED 2 GUARANTEE 3 INSURANCE []4 SURETY BOND <br /> E] 5 LETTER OF CREDIT Q 6 E*MPTION W 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 BILL3NG: I. if. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEOGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# _ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL 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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINS <br /> FORMA(3+93) � � F41ROlIa3A-R7 <br />