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STATEOFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH LITY/SITE °.1"cl ." <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT' <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 8 TEMPORARY SITE CLOSURE �] <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) - <br /> DBA OR FA�NAME NAME OF/V(:%6&4& <br /> OP BATOR <br /> SAP I"(:% ^ Ae'- z7&r Ly <br /> ADDRESS NEARESjCRO REQ PARCEL 4(OPTIONAL) <br /> CITY NA STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY- Q STATE-AGENCY' Q FEDERAL-AGENCY <br /> DISTRICTS <br /> If owner of UST is a public agen ,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAMEST,FIRST) PHONE#WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ( <br /> NITS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 7 zac - 6V-gs-a-C, <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ..i ✓bo Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> �7 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CM NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �-- s 3 <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW JCC CARE OF ADDRESS INFORMATION <br /> MAILIN R STREET ADDRESS ✓ bindicate Qf INDIVIDUAL QMAL-AGENCY Q STATE-AGENCY <br /> _ 7 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA COOS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)321-9669 if questions arise. <br /> TY(TK) HQ 4 4-11011 7 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 0 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,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 6++ PW /(� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> f lL� , <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 /> OWNER MUST FILE THIS FO, WITH THE LOCA-AGENCY IMPLEMENTING THE UNDERGRQ�IN•D STORAGE TANK REGULATIM <br /> FORMA(3/93) FOg0033A p7 <br />