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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FORE FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S N <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ACt ITY NAME NAMEOFOPERATOR <br /> AD R SS NEAREST CROSS STREET PARCEL#(OP510NAL) <br /> F ee.7�" <br /> CITVN E STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> CK-I' CA <br /> ✓ BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY ] COUNTY-AGENCY 1] STATE-AGENCY I] FEDERAL-AGENCY <br /> DISTRICTSTYPE OF BUSINESS O 1 GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKy AT SITE E.P.A. I.D.#(optional/ <br /> O 3 FARM 0 4 PROC SSOR O 5 OTHERO RESERVATION / <br /> 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓EoxbiMicale ] INDIVIDUAL LOCAL-AGENCY I]STATE-AGENCY <br /> I]CORPORATION I] PARTNERSHIP (] COUNTY-AGENCY I] FEDERALAGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Dox blMkat# INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> ]CORPORATION (] PARTNERSHIP I] COUNTY-AGENCY O FEMRAUAGEHCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA-CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE F&ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eox bintlkale I] 1SELF-01SURED ] UARANTEE [ 3 INSURANCE ]4 SURETYBOND <br /> O 5 LETrEROFCREDT W6 EXEMPTION I] W OTHER ��jj �/h e/ <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles OXToflI idcd.. C- <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Ev II.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# �7% JURISDICTION# FACILITY# <br /> LOCATION CODE - T NAL CENSUS TRACT OPT <br /> / U <br /> Nq&� VISO <br /> SUPR-DISTRICT CODE -OPTIONAL <br /> 4/ <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A("I) <br /> (F—FOOIiNKIAA-55 I <br />