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STATE OF CAUFOFNA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORMA A` <br /> OlVil Cr y OI <� <br /> SdS COMPLETE THIS FORM FOR EACH FACILITY/BITE <br /> ENARK ONLY ❑ O NEW PERMIT • c•i P•M•- <br /> ONE ITEMARKONL ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ <br /> ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT T PERMANENTLY CLOSE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) a TEMPORARY SITE CLOSURE <br /> DBA FACILITYNAME <br /> Ile <br /> AD ESS ME OF OPERATOR <br /> _ T <br /> S <br /> CITY A NEAREST CROSS STREET <br /> PARCEL AIOPrgNAC <br /> ' STATEv Box 21P CpDE <br /> 7�� CA SITE PHONE A WITH AREA CODE <br /> TOINDICATE 0 CORPORATION ) K INDIVIDUAL 0 PARTNERSHIP -- <br /> -I avnar d UST Is a Public agency.m th ll g O DISTRICTS <br /> - CpUMY AGENCY' <br /> P aB Y mWde the Iplipryln :name al SePeN6cr d division.section.m ffe whbh � STATE-AGENCY <br /> TYPE OF BUSINESS operates the UST 0 FEDERAL#GENCY <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR <br /> I❑ 3 FARM ❑ ✓ IF INDIAN A OF TANKS AT SITE E.P.A.❑ / PROCESSOR 5OTHER RESERVATION LD.vtgm,,w) <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS <br /> DAYS: N ME(LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDAp <br /> _ n1 �� � PHONE WITH AREA CODE Y)-Gp(Ipggl <br /> V C �D 3 DAYS: NAME(LAST,FIRST <br /> _ PHONE I WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) HONE ITH A A CpDE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> C CARE OF ADDRESS INFORMATION <br /> MAIL R STR E ADDRESS ��LL <br /> ✓ boabindbaR NDIVIDUAL <br /> CRY ENCY <br /> NAME CORPORATION O LOCAL-AGENCY NCV = FEDERSTATEAL <br /> AGENCY(] PARTNERSHIP �COUMYgGENCY �FEDEML-AGENCY <br /> TA ZIP CODE PHONE A WITH AREA CODE <br /> R TANK OWNER INFORMATION-(MUST BE COMPLETED) a 7 <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓5oa biMbad 0 INDIVIDUAL IJ LOCAL AGENCY STATE AGENCY <br /> CITY NAME O CORPORATION f= PARTNERSHIP 0 COUNTYAGENCY Q FEDEMLAGENCY <br /> STATE 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 /> ✓ <br /> box to Indicate 0 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE A SURETY BOND <br /> 5 LETrER OF CREDIT =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 /> 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 TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY p <br /> COUNTY g JURIS�• FACILITY D�gDO <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 Br UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL <br /> OWNER MUST FILE THIS FORMWITH THE LOCAL Mi9M 11@LEIEMIHGTHE UNDERGROUND STORAGE TAIM R[{RRILTIONb <br /> FORM A(S93) OWNER <br /> �gtdd�To � 3� po ru7� �c�1,LLCL �r 14 ` X-��53L3 <br />