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�,y;y"a''�"t'.�i' :�..:��1 A'�E:...� � '`F N r s ": 4}a..,.,�3y,,�V n P�S'"�`i• � <br />}1 <br />%k <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM [:] 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARS TCROSSST EET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP 60DE SITE PHONE#WITH AIR <br /> CA IEA CODE <br /> TOINDI ATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY <br /> COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRIIf 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 a 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.;V(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) 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#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 INDIVIDUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> =CORPORATION Q PARTNERSHIP E�j COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME` Q STATZIP CODE HONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Y <br /> NAME OF OWNER CARE OF ADDREINF RMATION <br /> MAIL(NGORSTREET ADDRESS 4/,arr AvE. S[rr'7� ✓ boxbindcate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP E:1 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P,.HONE# TH AREA CODE <br /> G> ,GF ! _ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -101011 ' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate t SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 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: L El II.0 III.a <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY If JURISDICTION# FACILITY# <br /> f -Jtr <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKW <br /> FORM A(3(93) . FOR0033A-R7 <br />