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sss " e <br /> STATE OF CALIFORNIA r' <br /> STATE WATER RESOURCES CONTROL BOARD 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOREACH CILITYISITE <br /> MARK ONLY O <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE X <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> t�P <br /> ADDRESS ` NEAREES CROSS STREET PARCEL#(OPTx)NAq <br /> G �Gd <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> e�f­ CAI/ BOX <br /> TO INDICATE 0 CORPORATION (] INDIVIDUAL I= PARTNERSHIP EA LOCAL-AGENCY COUNTY AGENCY STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 RV IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal/ <br /> Q ON <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) 1 PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> PHnNg A WITH AREA CMF <br /> NIGHTS: ME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) MP#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bwblmicaU 0INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> D CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY 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 /> aevW uS .7 <br /> MAILING ORSTREETADDRESS ✓ b"01micad 0INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ a s - 0 131 a I aa- 6 <br /> V. PETROLEUM UST FINANCIAL ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa blMkMe 7SELF-INSURED 2 GUARANTEE 0 9 INSURANCE E:j d SURETY BOND <br /> 0 5 LETrER OF CREDIT 6 EXEMPTION 0 97 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. 0.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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# .. <br /> LOCATION CODE -OPT/ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTR DE -OPTIONAL <br /> d 3.;t 3pl(o �' <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 /> FORM A(5-91) 1010053AI \ <br />