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• 'C6 V- C <br /> f i <br /> STATE OF CALIFORNIA � <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> �-tlfoRM'` <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSE©E <br /> MARK ONLY ❑ S TEMPORARY SITE CLOSURE <br /> ONE ITEM F-14 AMENDED PERMIT 2 INTERIM PERMIT ❑ <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAMEOFO RAT FI 0 r v <br /> D ORF71LITY NAM &Y '/•)r <br /> CHIC NEAREST CROSS$TREET PARCELNIOP ONAU <br /> DDRESS �] ry J_./: <br /> SITE PHONEN WITH AREA CODE <br /> CITY NAME STATE ZIP zd� <br /> ✓ Pox LOCAL-AGENCY CAUMVAGENCY' O <br /> STATE AGE O FEDEPALAGENCY <br /> TO INDICATE CARPoMTION INDIVIDUAL PARTNERSHIP ] DISTRICTS' <br /> •M vaner d UST la a public agency,w Isle the following:^ of Supervisor d divkbn.section.or office whkata the UST — <br /> �opNrINI I AN NOF TANKS AT SITE E.P.A. 1.D.N(optional) <br /> TYPE OF BUSINESS 7 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE N WITH AAQODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> DAYS: N E(LAST,FIRST)//�� C� <br /> VI PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHO E N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME r <br /> u ✓ bNbindIoW E3 INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY <br /> MAILING OR STREET ADDRESS ]CORPORATION ]PARTNERSHIP ]COUNTYAGENCY ]FEDERAL-AGENCY <br /> Q' STlyTZIP _DE PHONE N/WIT AREA <br /> / Z <br /> CITY AME � C� ZU (J <br /> c k-`ca n Y <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> r! eL <br /> ✓ bon bindkc ] INDIVIDUAL ] LOCAL-AGENCY STATEAGENDY <br /> MAI ING OR ST EET ADDRESS <br /> Vl CORPORATION O PMTNEASHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> STATEZIP COPE PHONEWIT AREAD�LE <br /> CITY NAME (_59 <br /> z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ] 1SELF-INSURED E32 GUARANTEE L::] 3 INSURANCE <br /> CES+ ]4 SURETY BQIIG <br /> 1/ bov biMkate 5 LEITER OF CREDIT ]B EXEMPTION I dJ <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: <br /> I.❑ II.❑ IN.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 8 SIGNED) <br /> OWNER'STRLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 7777 <br /> FACILITY# <br /> ® 0R-DIST K:T CODE -OPTlOAWIL <br /> LOCATpN CODE -OPT m CENSUS TRACT N OPTIONAL 2� L �^T7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR 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 Fdtow T <br /> FORM A(393) . • \�� �� <br />