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� C <br /> h� i <br /> STATE OF CALIFORMA , ?e <br /> STATE WATER RESOURCES CONTROL BOARD a S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA `� . . 9 0 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY J 1 NEW PERMIT F__j 3 RENEWAL PERMIT >!�p CHANGE OF INFORMATION E�] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR ACILITYNAME NAME OF OPERATOR , <br /> ADDRESS NEAREST CROSS STREET P L>r(OPTIONAu <br /> GITY NAME STATE ZIP CODE ITE PHONE WITH AREA CODE <br /> ✓ BOX LOCAL•AGENCY COUNTY-AGENCY' 0 STATE-AGENCY` FEDERAL-AGENCY' <br /> TOINDICATE f]CORPORATION INDIVIDUAL � PARTNERSRP (] I� <br /> DISTRICTS' <br /> It owner of UST is a public agency,oomplete 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 s�OF TAIlK5 AT SITE E.P.A. I.D.S(optima!} <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME iLAST.FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> .r7 a C 020 1 ,r <br /> NIGHTS: NAME(LAST,F I ST) W PHONE a WITH A EA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> I I /s r7 73 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME(,,, '? - f, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRS �'� ✓ box IDindrcAle l] INDIVIDUAL ® LOCAL-AGENCY l] STATE-AGENCY <br /> �� CORPORATION = PARTNERSHIP i] COUNTY-AGENCY [� FEDERAL-AGENCY <br /> CITY NA S ZIP CoO PHOryE�Wt H AREA CODE <br /> e2 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo" Indicate INDIVIDUAL LOGAL-AGENCY (] STATE-AGENCY <br /> (]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Cf FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TIC) HQ M44- - ... <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ twx loindicate F71 1 SELF-INSURED F-1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 0 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 ll is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: Ix II.E III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE$EST CIF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY Te-_C_ -) '�'3 f <br /> COODUUN{TTYY]�# JURISDICTION# FACILITY# <br /> 101 el I i/ <br /> 72 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT v = TIONAL SUPVISOR-DISTRICT OPTKOAIAiL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)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 FORom3A-117 <br /> FORM A(3/83) <br /> � - _ ' <br />