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6pyA <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ��tiroRN`' <br /> MARK ONLY O t NEW PERMIT E:] 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ON FACILITY N NA E OF OPERATOR <br /> C, u '- IT- GI LrL_ <br /> ADDRESS NE EST CROSS STREET PARCEL#(OPTIONAL)q-5k P E <br /> Ir <br /> CITY NAME �� STACEA ZIP�pDE TE PHNE a�WITH AREA CODE <br /> -yyI/ BOX <br /> TO INDICATE E::)CORPORATION 0 INDIVIDUAL (;PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY 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 0 ✓ IF INDIAN #OF TA10S AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION ^ <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY NAME( ST,FIRS HONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Uj <br /> 'j 3_ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> E <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> R. GU fl-IT <br /> MAILING OR STREET ADDRESS " <br /> box b indicate NDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> 2 G l p CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST/\T�, ZIP QQD�� P NE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) Il'/I//1t /GJC�J 5 <br /> NAME OF OWNER ��p CARE OF ADDRESS INFORMATION <br /> ®5 t As I�r 0 <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN 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 4-11012- (3] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER 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 x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.F-1 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&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> In] FTT1 wz 3 0 D 2I � <br /> LOCATION CODE -TTIONAL CENSUIsT#�OPNAL SUPVIIR-D TR T CODE -OPTIONAL <br /> (f t U <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKW <br /> FORM A(3(93) FOR0633A-R7 <br />