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".au r. <br /> r <br /> STATEOFCAUF41iN1A A <br /> STATE WATER RESOURCES CONTROL BOARD W,ate, v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> 0 <br /> COMPLETE THIS FORM FOR <br /> �EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT DG I 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSRiTr <br /> ONE REM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT /�� 6 TEMPORARY SITE CLOSURE <br /> L FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA ORF ITY NAME NAME OFOP TQR <br /> ADDR 55 NEAR <br /> C�ROSSSTR�Elr PAACEtN(OPTIONAL) <br /> CSTATE ZIP CSITE PHONE#0 WITH AREA CODE <br /> CA � ' <br /> lb <br /> 7 86X <br /> TO fNOICATE 0 CORPORATION 0 INDIVIDUAL PARTNERSHIP q LOCAL-AGENCY Cl COUNTY-AGENCY' 0 STATE-AGENCY' L FEDERALAGENCY' <br /> DISTRICTS' <br /> 'If owner of UST is a public agency,complete the following:name o1 Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR [=] ✓ IF INDIAN I#OF TAN S AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS f <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA : NAME(LAST,FIR T) r PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL F-1 LOCAL-AGENCY C] STATE-AGENCY <br /> []CORPORATION © PARTNERSHIP COUNTY-AGENCY O 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 Indicats © INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTY-AGENCY FLOERAL-AGENCY <br /> CITY NAME STATE ZiP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 1414- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box tairdicate 1 SELF-INSURED ]2 GUARANTEE 771.3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 6€XEMPTiON m 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. if.[�:] 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'STRLE DATE MONTWDAYlYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �� FACILITY# <br /> LOCATION COD -OPTIONAL CENSUS TRA # -OPTIONAL 7567pV[SOR-O ICT p€ - <br /> 9 <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(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �' '-7 1, `� /07 <br /> R7 <br />