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STATEOFCAUFORNIA �* 1'0 <br /> STATE WATER RESOURCES CONTROL BOARD W 40�� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED$f <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME .> NAME OF OPERATOR <br /> ADDRESS NEARES CROSS ;TREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP O1bDE SITE PHONE#WITH AREA CODE <br /> ✓ BOx <br /> TO INDICATE ER!"CORPORATION CORPORATION [:1INDIVIDUAL El PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' [:1 FEDERAL-AGENCY <br /> DISTRICTS' <br /> If 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 t GAS STATION 2 DISTRIBUTOR E:�] ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> Q 3 FARM 4 PROCESSOR Q 5 OTHER ORTRUSTVATION LANDS ¢� 600035 IOC, <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMfERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAM ST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NI TS: 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 bindicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 1 STATE ZIP CODE PHONE#WITH AREA CODE <br /> rV <br /> III. TANK OWNER INFORMAtIO MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS, ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> C]CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <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 /> ✓ <br /> box io indicate Ci 1 SELF-INSURED (]2 GUARANTEE 3 INSURANCE Q 4 SURETYBOND <br /> D 5 LETTEROFCREDIT Q 6 EXEMPTION Q 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> i <br /> COUNTY# JURISDICTION# FACILITY# —7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIOM4L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SR'E INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM <br /> FORM A t3!!XA � � FOR0033A-R7 <br />