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! <br /> A! <br /> STATE OF CALIFORNIA 'o <br /> STATE WATER RESOURCES CONTROL BOARD W ngg Ye a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA a r I, <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE fll�fU-"�- <br /> MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY C <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 It TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nPA ORFACILITY NAME NAME OF OPERATOR <br /> ADDR SS NEAREST CROSS STREET ,q +PARCEL#(OFfIONAU,i! , i SCITY NAME / STATE r ZIP CODE E PHONE#WITH AREA CODE <br /> T 10 Np ATE CORPORATION O INDIVIDUAL E] PARTNERSHIP I7 LOCADISTCTS NCY O COUNTYAGENCY' STATE-AGENCY' O FEDEIUL#GENCY' <br /> 'II owner of UST le a public agency,conplete the following:name of Supervisor of division.rection,or oNlse whbh operates the UST <br /> 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(gNxnal) <br /> TYPE OF BUSINESS 1 GAS STATION <br /> D RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DArS: NAME(LAST,FIRST) PHONE a WITH AR CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ro a S o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHA ACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> LNAMEREET AOORESS ✓ bosbirdbate D INDIVIDUAL LOCAL �STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY (] FEOERALAGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> WAILING OR STREET ADDRESS ✓ bot bintlnaN INDIVIDUAL OLOCAL-AGENCY STATEAGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY � FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -�] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bosbintlbsM 1� 1 SELF-INSURED �2 GUARANTEE 7 INSURANCE 1�4 SURETY BOND <br /> �5 LETTEROFCREDIT D&EXEMPTION 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.D Ill.E <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) OWNERS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY ec I D a 3 a 4 h <br /> COUNTY# JURISDICTION# FACILITY# <br /> CATION CODE -OPTIONAL $U3' <br /> CENTRACT;1 -OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL <br /> LO <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,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 FORWJxA7 <br /> FORM A(3/93) 0 <br /> 0 <br />