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STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA Ys . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �, F <br /> L pq Nv <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OA OR FACILITY NAME y� NAME OF OPERATOR <br /> ADDRESS .. �EAFIEST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE Zip CODE SITE PHONE#WITH AREA CODE <br /> kj CA <br /> ✓BOX CORPORATION INDIVIDUAL PARTNERSHIP a LOCAL-AGENCY COUNTY-AGENCYQ STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS } Fti1 J t �. r '1 -' — J 7 k <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 ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 RESEIRVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> E CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, RS ,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 If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CQDE PHONE#WITH AREA CCDE� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N?E OF OWNER \ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> INDIVIDUAL QLOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP IJ'COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITX,NAME STAT ZIP CO}r.QE / 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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> be box to indicate 1 SELF-INSURED =2 GUARANTEE 4 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 177 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.❑ IL 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTW YNEAR <br /> r ) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ❑ FTTI I I I I I <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 /> FORMA(6-95) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIONS <br />