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C 0 0 � us <br />I STATEOFCAUFOINBA J' U'�o <br />/ STATE WATER RESOURCES CONTROL BOARD W .,�� .- <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , , <br />COMPLETE THIS FORM FOR EACH FACILRY/SITE `'t��nR+`' <br />MARK ONLY <br />D t NEW PERMIT <br />3 RENEWAL PERMIT <br />5 CHANGE OF INFORMATION <br />O 7 PERMANENTLY CLOSED <br />ONE REM <br />Q 2 INTERIM PERMIT <br />Q 4 AMENDED PERMIT <br />5 TEMPORARY SITE CLOSURE <br />g <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FAC ITY NAME//'-�� <br />dkAZ S LtH <br />NAME OF OPE OR //// <br />Z.Gpy.5-., - <br />ADDRESS LJI <br />NEhRi9TR <br />—2, 1a3I <br />PAfCELA(OPfONAy <br />z3 J <br />NIGHTS: NAM <br />T, FIRST) PHONESWITH AREA CODE <br />CITY NAME <br />CA STA <br />I e)ZIP CODE�� C r <br />SITE <br />I-3 AREA <br />v� <br />000b/ <br />' <br />I= CORPORATION PARTNERSHIP <br />S�PHONE <br />5 /S_ <br />TOINGCATE O CORPORATION INDIVIDUAL = PARTNERSHIP O LOCAL -AGENCY O COUNTY -AGENCY' O STATE -AGENCY• O FEDERAL -AGENCY' <br />I <br />' It owner of UST IsapubAc age , mrrpI!. the following: name of Supervisor of dNMbn, section, or o8ioe which operates the UST <br />TYPE OF BUSINESS 7 OAS STATION 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br />a OF TANKS AT SITE E. P. A. I. D. * (option# <br />0 3 FARM 0 4 PROCESSOR Q S OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ootlonal <br />DAYS: NAME (LAST, FIRST)PHONE <br />S <br /># WITH AREA CODE <br />Camra w_ 5 3 o <br />DAYS: NAME LAST, <br />"S <br />FIRST) PHONE 4 WITH AREA CODE <br />NIGHTS: NAME T, FIRST) <br />PHONE #WITH AREA CODE <br />NIGHTS: NAM <br />T, FIRST) PHONESWITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAM^ <br />1•.�(Jx/ <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREETADDRESS / <br />✓ boxbintlkate (] INDIVIDUAL O LOCAL AGENCY O STATE -AGENCY <br />QCORPORATION (]PARTNERSHIP COUNTY AGENCY FEDERAL -AGENCY <br />CITUNAME <br />STAT^ <br />ZIPCODE <br />PHONESWITH AREA CODE <br />✓ bmbimicale INDIVIDUAL <br />D LOCAL -AGENCY STATE -AGENCY <br />I <br />' <br />III. TANK OWNEh INFORMATION - (MUST BE COMPLETED) <br />NAMED WNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ bmbimicale INDIVIDUAL <br />D LOCAL -AGENCY STATE -AGENCY <br />' <br />I= CORPORATION PARTNERSHIP <br />O COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />I <br />STATE <br />ZIP CODE <br />PHONE a WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HO M44- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ boa bbdkato D I SELF-INSURED 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br />D 5 LETTER OF CREDIT Q 6 EXEMPTION w 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 ❑ IL ❑ 111- 12" <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />OWNERS NAME (PRINTED & SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY# JURISDICTION# FACILITY# - <br />LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR- DISTRICT CODE -OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION- FORM 0, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORMAPIll 0 <br />j/ -L FOR0033AR7 <br />