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OV RC!'S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA rs s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �' <br /> C1l,FOR N� <br /> MARK ONLY 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY OSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> — <br /> ADDRESS NEAREST CROSS STREET PARCEL Y(OPTIONAL) <br /> it <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 7o T �I CA (7:S-�2 .o -7 <br /> ✓BOXCORPORATION Q INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE 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 1 GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 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) P ONE#WITH AREA CODE <br /> NIGHTS: NAM (LAST,FIRST). PHONE#WITH AREA CODE NIGHTS: NAME(LA ,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 E:1 LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION (]PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> IA[apz A) <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> F III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARERF ADDRESS INFORMATION <br /> 4241 <br /> MAILING OR STREET ADDRESS ✓ boxto irclicate CD INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE If WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> k TY(TK) HO 4 4 - <br /> f V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION EJ 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0,,9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 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 EOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY 6Pr PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE f MONTHNDAYNYPAR <br /> 'M�9_f" <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m - , , <br />` LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> r THIS FORM MUST BE ACCOMPANIED BY AT IM(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS A CHANGE OF SITE INFORMATION ONLY. <br /> I OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO ORAGE TANK REGULATIONS <br /> i FORM A(6-95) <br />, <br />