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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION 8&ADDRESS-(MUST BE COMPLETED) O <br /> DB ORFACILITYNAM NAMEOFOPERATOR <br /> I/ ALd <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONALI <br /> 6 25 i4wil <br /> CITY NAME QC19 — <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> an CA �lSLu'U <br /> ✓ Box <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' I!]STATE-AGENCY' FEDERAL-AGENCY' <br /> Avner of UST Is a public agency.W nplel6 the lollowing:name al Sopervbor of division,sectionDor office whbh <br /> operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.a(optimal) <br /> 3 FARM 4 PROCESSOR O 5 OTHER O RESERVATION <br /> ORTRUSTLANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAPE OF ADDRESS INFORMATION <br /> US AS L� <br /> MAIL NAME STR(�EETADDRESS ✓Oox bindlpU INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O p0 7G =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL CITU NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Sr��wI�GC �,� KS 6Zo _4/3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> V <br /> MALING OR STREET ADDR SS ✓ box biMipN 0 INDIVIDUAL = LOCAL AGENCY <br /> 30 -74- CORPORATION STATE-AGENCY <br /> CITY NA E D PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> S/I,lC" iSSio, 66zz q <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 /> ✓ box lo Indicate 0 1 SELF INSURED L_j 2 GUARANTEE <br /> ID 5 LETrEROFCREDIT (] 3 ITHER CE O 4 SURETY BOND <br /> 0 6 EXEMPTION O <br /> 0 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: <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 IF 4TH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> T FACILITY M <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT 8 -OPTIONAL 9U ��STRICT CODE -OPTA7NAL <br /> 3 - Z <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 /> FORMA(3W) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /(„ FOR0033AV <br />