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0 i <br /> STATE OF CAUFORNIA .r s <br /> STATE WATER RESOURCES CONTROL BOARD nom' <br /> t �f UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY LJ 1 NEW PERMIT F__] 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FAC ITY NAMENAME OF OPERATOR <br /> ADORE- NE EST CROSS STREET PARCEL$(OPTIONAL) <br /> � r 7_ <br /> CITY NA STATE ZiP D SITE PHONE#WITH AREA CODE <br /> CA <br /> DtSTRC <br /> I/ BOX <br /> 7O INDICATE CORPORATION C] INDIVIDUAL 0 PARTNERSHIP LOCAL AGENCY COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> TS' <br /> II owner of UST Is a public agency,complete the following:name of Supervisor of dlvxbn,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION L] 2 DISTRIBUTORREV IF SER INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM I7 4 PROCESSOR [=] 5 OTHER OR TRUST LANDS <br /> EMERG NCY 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 ILAST,FIRST) PHONE#WiTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFO ATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bind"te INDIVIDUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Wicale = INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> (]CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COOS ______TPHONE#WITH AREA CODE <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACC NT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4 4- - F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindieale 0 1 SELF-INSURED (] 2 GUARANTEE 0 3 INSURANCE 4 SURLTYEOND <br /> = 5 LETTER OF CREDIT 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.❑ IL❑ III.❑ <br /> THIS FORM NAS 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 /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPR-DISTRICT CODE -QPTIONAL <br /> G? VISO <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(3/93) FORlxl33A-R7 <br /> • r �' t1� <br />