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1 \ <br /> STATE OF CALIFOpIyA <br /> v STATE WATER RE30UgCES CONTROL BOARD ° ne6W c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACfUTY/SITE <br /> MARK ONLY Q 1 NEW PERMIT ^ `'�•onn" <br /> ONE REM 0 S RENEWAL PERMIT CHANGE OF INFORMATION O <br /> Q 2 INTERIM PERMIT 0 0 AMENDED PERMIT [LJ�— T PERMANENTLY CLOSED SITE <br /> B TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPFMTOq <br /> ADORESAt Tr_ <br /> 5 5 NEAREST CR OSS STREET PARCEL#(OPTONAL) <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TO Np 1TE O conFogATK)N CA 3 <br /> INDIVIDUAL <br /> 0 PARTNERSHIP 0 LOCAL-AGENCY <br /> 'N owner d UST le a pub6e agency,r>omplAle Ure l DISTRICTS' 0 COUNryAGENCY' O STATE-AGENCY' 0 FEDERAL.IGENCY <br /> dowMB:narrg d Superv6or d tlN4km,eectpn,W duce which OPWWW the UST <br /> TYPE OF BUSINESS O I (SNS STATION 0 2 DISTRIBUTOR / <br /> L1�O/ O RESERVATIF OK)N a Tµ AT SITE E.P.0. I.D.a(cptlyylj <br /> 0 3 FARM E 4 PROCESSOR 5 OTHER <br /> OR TRUST LANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY COMACT PERSON (SECONDAR <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE Y)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE•NATH AREAMEA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE*MTN AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOS <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> �. CARE OF ADDRESS INFORMATION <br /> MAIL NO OR STREET ONE V, box bYHksb <br /> 3r ED INDIVIDUAL O LOCAL-AGENCY D STATE-M;ENCY <br /> . S 0 CORPORAnoN HIP <br /> CITY NAA$ PARTNFAS0 CWNry#GENCY 0 FFDEMLAGENCY <br /> STATE ZIP COCE PHONE#WITH AREA CODE <br /> Z � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box IoNtlkm <br /> 0 INDIVIDUAL QLOLL-AGENCY �gTATE-AGENCY <br /> CITY NAME 0 CORPORATION O PARTNERSHIP O COUNry.AMNCY 0 FEDERALAGENCY <br /> STATE ZIP CODE PHONE s WITH AREA COOS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUM <br /> TY(TK) HQ M44- - BER-Call(916)322-9669 if questions arise. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> O O 4 SURETY BOND <br /> 5 LETTER OF CREDIT <br /> O 6 EXEMPTION [_:1 sp OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE GATE MONTHOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION C FACILITY i Od 3.ZgT <br /> ED 0 1 f 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL BUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3197) FCNaRi]AAT <br />