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• `� VII <br /> �T STATEOFCAUFORNIA <br /> / STATE WATER RESOURCES CONTROL BOARD W v n <br /> f UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORMA e i <br /> ✓Y COMPLETE THIS FORM FOR EACH FACILITY/SITE „,- <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAOR L NAME A/J NAMEOFOPERAT R <br /> ADORj NEAUNEVCROSSSTRWPARCEL#IOPTONAU <br /> Ce <br /> CITY N STATE IP COpG. / SITE PHONE a WITH AREA CODE <br /> I'Iry CA <br /> I/11OX <br /> TOINDICATE D CORPORATION ED INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY• D FEDERAL-AGENCY' <br /> II owner o(UST is aagent ublic y a DISTRICTS' <br /> p ,complete the following: of Supervisor of tlNbbn,section,or onice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTORM ✓ IF INDIAN N OF TAN IjS AT SITE E.P.A. I.D.a(cptbnel) <br /> ❑ RESERVATION / <br /> Q 3 FARM ❑ 4 PROCESSOR 5 OTHII/\ER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabinOkms 0INDIVIDUAL El LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORADON I1 PARTNERSHIP I1 COUNTY-AGENCY I1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box lo Indicate D INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> ED CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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- - IZ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bIndicale Q 1 SELF INSURED (] UMANTEE Q 3INSURANCE I�4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless Is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L I.❑ 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 a SIGNED) OWNER'S TITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# # <br /> LOCATI .OPTIONAL CENSUS TR Ta -OPT SUPVISOR. ITRICT E -OPTIONAL <br /> 3. �72_I O <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(393) NS <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE T REGULATION <br /> FOR0033A{IT <br /> l )SH3 * �1�� <br />