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l6F ! <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 B TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIl-ITY NAME ! NAME OF OPERATOR r� <br /> ADDAES9 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAIL F r STATE ZIRCQOE SITE PHONE P=ONE AREA CODE <br /> CA <br /> I/ BOX <br /> TD NDIC TE LJ,CORPORATION [_1 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY I—] COUNTY-AGENCY' [] STATE-AGENCY' [7 FEDERAL-AGENCY <br /> DISTRICTS' <br /> If owner of UST Is a public agency,conpMe the following:name of Supervisor of division,Section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P,A. I.D.#(optional) <br /> RESERVATION <br /> [] 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST 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 /> NIGHTS: NAME(LAST.FIRST) T PHONE#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 to Indicate Q INDIVIDUAL LOCAL-AGENCY [771 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> 0 INDIVIDUAL LOCAL-AGENCY []STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME i STATE ZIP CODE PHONE N WITH AREA CODE <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 /> ✓ <br /> box tc indicate I SELF-INSURED 0 2 GUARANTEE 7 INSURANCE 0 4 SURETY BOND <br /> D 5 LFTTFROFCREDIT I]6 EXEMPTION 0 99 OTHER <br /> V1. 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: L❑ il.[—] III. <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&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ELI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N •OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) 0 0 FORDaiaa-R7 <br />