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0 0 a us <br /> STATEOFCAUPORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 3 NEW PERMIT F7 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT F] 4 AMENDED PERMIT E:j 8 TEMPORARY SITE CLOSURE 50 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL A(ORIONAp <br /> /Z/ ---Ir C,�A E ' ' <br /> CITY NAME STATE ZIP CODE - SITE PHONE a WITH AREA CODE <br /> CABOX <br /> TO INDICATE O CORPORATION D INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY 0 OWNTYAGENCY' D STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'It owner of UST is a public agency,complete the following:name of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RE,/ IF INDIAN <br /> SERVATION A OF TANKS SITE E.P.A. I.D.s(optimal) <br /> Q 3 FARM 4 PROCESSOR Q-1 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE I DAYS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Inxl4lndkad INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> /Z /o ��- w� 7 D CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 to Indicate INDIVIDUAL O LOCAL-AGENCY = STATE AGENCY <br /> I(^ O CORPORATION O PARTNERSHIP D COUNTY AGENCY Q FEDERALAGENCY <br /> CITY NAME STATg ZIP 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0 wicale 0 I SELF INSURED 0 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETrEROFCREDIT O 6 EXEMPTION 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 /> CHECKONE 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 /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAWYFAR <br /> LOCAL AGENCY USE ONLY <br /> COOUUINTY Iu JURISDICTION aY FACILITY a <br /> W <br /> LOCATION CODE -OPTIONAL CENSUSTRACTa -OPTIONAL SUPVISORDISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) 0 <br /> FOR0D33A1R7 <br />