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STATE OF CAUFORMA ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA a <br /> COMPLETE THIS FORM FOR EACH FACILITYISI'TE <br /> MARK ONLY I NEW PERMIT a 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM 35< INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRP OR AGILITY NPNE NAME OF OPERATOR <br /> NEAFIJST CROSS STREET PARCELJ(OPIIONAM <br /> ADORE <br /> CITY NAME STATE ZIP SITE PHONE)WITH AREA CODE <br /> 0 CA <br /> ✓ BOXLOCAL-AGENCY 0 COUNIYADENCY' D STATE-AGENCY' O FEDERALAOENCY• <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP DISTRICTS' <br /> •I owner of UST Is a public agency,mrr4A"the folloWng:nanw of Supervisor of dMsbn,section,or office which operates Nle UST <br /> ✓ IF INDIAN J OF TANKS AT SITE E.R A. I.D.a lophOnal) <br /> TYPE OF BUSINESS <br /> 1 GAS STATION Q 2 DISTRIBUTOR E:771 RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIRST) P E I EATREAC EDAYS: =FIRST) <br /> PHONE J WITH AREA CODE <br /> PHONE J E _ (LAST. <br /> PHONE J WITH AREA CODE <br /> NI S: NAME(LAST,FIRST) L/v <br /> Y4 V 40 <br /> II. PROPERTY 0 NER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORVPARTNP <br /> MAILING OR STREET ADDRESS ✓ EMbimmme L LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q COUKTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE Be CODE PHONE I WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(M T BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ bulcindicNe O INDIVIDUAL LOCAL AGEKY STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP C71 COUNTY-AGENN FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9 WITH A CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -LI 1 U <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bh9cm f SELF INSURED Q 2 GUARANTEE Q 7 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT 8 EYEMPTION 9B 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II.D III. <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 B SIGNED) OWNER'S TRUE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY i JURISDICTION R FACILITY• <br /> FT-1 <br /> LOCATION/C IF-OPTN)NAL CENSUS�M.(CTJ-OPTp , SUWA90R•DISTRICTC�-OPRONAL <br /> V a,(✓A <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 /> FORMA 3'93 OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />