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N <br /> egou-acs I <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 /> �E <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> l <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> I <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX &?6RPORATION [] INDIVIDUAL CD PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> I 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 /> CTYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTORgESEIgVAONF D AN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR Q"'5 OTHER OR TRUST LANDS ►�� """ <br /> I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> jDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS:INAME(AST,FlRST) PHONI NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> a <br /> AILING OR STREET ADDRESS ✓ boxto indicate E:D INDIVIDUAL Q LOCAL-AGENCY a STATE-AGENCY <br /> i ['SRPORATION Q PARTNERSHIP E::]COUNTY-AGENCY FEDERAL-AGENCY <br /> I CITY NAME STATEZIP CODE P NE'p WITH AREA CODE <br /> r <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL ED LOCAL-AGENCY E�j STATE-AGENCY <br /> i g?60'RPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE It 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 /> - a1 <br /> 3 1, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND <br />(E. 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT O 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. II. III. <br />{ <br />! THIS FORM HAS BEEN COMPLETED U PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> In fi* <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) olf 'S TITLE DATE MONTHiDAYNEAR <br /> .� I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT IM(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLMWORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />