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1 <br /> ,OUR <br /> F ivek• C <br /> STATE OF CALIFORNIA <br /> ?a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY)SITE `•��4„"'� <br /> MARK ONLY f NEW PERMIT a 3 RENEWAL PERMIT E�j 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS T-E- <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT $ TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0.fJCILITYNAME NAME OF OPERATOR <br /> /LII. •� !� <br /> :AD�IDRESSpc NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Cl7Y NAME STATE ZIP CppE �} SITE PHONE# ITH AREA CODE <br /> -� GA �rJ 6 y � <br /> .,7—Box, (CORPORATION [I INDIVIDUAL 0 PARTNERSHIP ® LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE ; ` DISTRICTS' <br /> 'if owner of UST is a public agency,complete the following:name of Superv*or of division,section,or office which operates the UST <br /> TYPE OF BUSINESS f GAS STATION ® 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opNanal) <br /> 0 3 FARM 4 PROCESSOR I= 5 OTHER OR TRUST RESERVATION <br /> LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> —S-C& ,1 / 1)J � <br /> NIGHTS: NAME(L ,FAST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blndicate INDIVIDUAL ® LOCAL-AGENCY STATE-AGENCY <br /> [�CORPORATION PARTNERSHIP COUNTY-AGENCY LFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATF-AGENCY <br /> 0 CORPORATION PARTNERSHIP []COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME e 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 M44- _ ,, ✓,� C) <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate t SELF-INSURED = 2 GUARANTEE [] 3 INSURANCE 0 4 SURETY BOND <br /> 1� 5 LETTER OF CREDIT O 6 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.E lll. <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 a SIGNED) OWNER'S TITLE DATE MONTHJDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrrY#� <br /> LOCATION CODE -OPTIONAL aENSUS TRACT# -OPTIOYL SUPVISOR-DISTRII CODE -OP17OArAL <br /> THIS FORM MUST BE ACCOMPANIED 9Y AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 13 A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS_wzFO{iI fiHE-L-OOAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORM A(3W) / 1 11) 1 p 7 <br /> 0 ld,r X&,) 7" Q- <br />