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69`RCP4 Cr <br /> STATE OF CALIFORNIA ` ti <br /> I STATE WATER RESOURCES CONTROL BOARD w•� o <br /> z UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> • C•[1•pRH" <br /> t <br /> COMPLETE THIS FORM FOR EACH FAGILRYrSIT <br /> MARK ONLY ❑ t <br /> NEW PERMIT <br /> 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM L 2 INTERIM PERMIT <br /> '� 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OF OPERATOR <br /> DBA OR FAGILI NAME c t <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> AD RL S <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CI N ME _ 0 CA <br /> \__� COUNTY-AGENCY QSTATE-AGENCY � FEDERAL-AGENCY <br /> LOCAL- <br /> I/ BOX fY1 CORPORATION []INDIVIDUAL []PARTNERSHIP 4�RIC SFNCY <br /> TOINDICATE V DISTRIBUTOR REIF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> SERVATION <br /> TYPE OF BUSINESS 1 GRAS STATION 2 DIS5 OTHER OR TRUST LANDS <br /> 3 FARM Q a PROCESSOR <br /> EMERGENCY CONTACT RSON (PRIMARY) optional <br /> EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) <br /> RHONE#WITH AREA CODE <br /> DAYS: NAME(LAST.FIRST) ONEAAIV1I�LARF A C0DE �� <br /> NIGHTS: NAME(LAST,FIRST) <br /> ONE#WITH AREA ODDE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NArsF <br /> box lolndicata INDIVIDUAL []LOCAL-AGENCY Q STATE-AGENC <br /> MAILING OR STREET ADDRESS Q CORPORATION [� PARTNERSHIP 0 COUNTY_4.GENCY E_:] FEDERAL-AGENCY <br /> - PHONE#WITH AREA CODE <br /> STATE ZIP CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETE \ CARE of ADDREss wFORMATION <br /> NAME OF OWNER STATE-AGENCY <br /> box Windicate [] INDIVIDUAL p LOCAL-AGENCY [� <br /> MAILING OR STREET ADDRESS CORPORATION [] PARTNERSHIP 'COUNTY-AGENCY [� FEDERAL,-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME' <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Ca11 I 11 I(916)323-9555 it questions arise. <br /> TY(TK) HO [4—E4 ' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED}–IDENTIFY TN�METsHODES } USED E-14 SURETY BOND <br /> 0 2 GUARANTEE <br /> I i SELF-INSURED 6 EXEMPTION 99 OTHER <br /> box to indicate 5 LLTfEROFGREOIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing DillelbelN�nt to the tank owner unless box Ili ras checked <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS A <br /> IS <br /> RFCT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TD 7NE 9EST DF MY KNOWLEDGE,A TRUE AND M 11 ONTDWDAY YEAR <br /> RPPLICANTS TITLE <br /> APPLICANT'S NAME(PRINTLD&SIGNATURE) f <br /> 1 <br /> LOCAL AGENCY USE ONLY FACILITY# <br /> JURISDICTION# <br /> COUNTY# <br /> I I _L—�_I _ <br /> ` , SUPVISOR•DISTRICT CODE -OPTIONAL <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTI NALir <br /> 40 .` <br /> FORM UST B£ACGOMPANIED BY AT`LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INF�ORyM�AT40N ON . <br /> THIS F0R0033A- <br /> GORM A(12 9i) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND S7� ASCE TANK REGULATIONS � <br />