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I ,ice" L <br /> H to <br /> I STATE OF CALIFORNIA # <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> i COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF (NFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> +I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> f <br /> 6 <br /> l I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> S F DBA OR FACILITY NAME NAME OF OPERATOR <br /> 0i Au— CK <br /> 9 ADDRESS NEAREST CROSS STREET PARCEL t(OPTIONAta <br /> I CITY NAME STATE TIP CODE SITE PHONE x WITH AREA CODE <br /> TOI/ BOX <br /> INDICATE D CORPORATION INDIYIDUAL Q PARTNERSHIP Q LOCAL-AGENCY [] COUNTY-AGENCY' Q STATE•AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> I <br /> '11 owner of UST Is a public agency,complete the following:name of Supervisor of division,swioon',or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION [] 2 DISTRIBUTOR / ;y ❑ RESERVADION s OF TANKS AT SITE E.P.A. I.D.s(optional} <br /> 3 FARM 4 PROCESSOR � ` OTHER OR TRUST LANDS <br /> I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> GAYS: NAME(LAST,FIRS PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) r <br /> PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> 1 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADOR S / ✓box n WkM [] INDNIDUAL 0 LOCAL-AGFNCY [] STATE-AGENCY <br /> // 7 <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> i CITY NAME _ STATE ZIP CODE PHONE s WITH AREA CODE <br /> ` III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> i CARE OF ADDRESS INFO RMATION <br /> NAME OF OWNER <br /> i <br /> MAILING OR STREET ADDRESS ✓ box n m4ate 0 INDNIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 1] PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)322-9669 if questions arise. <br /> TY(TK) Fid <br /> f V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> box n ndicate = 1 SELF-INSURED ©2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT B EXEMPTION [] go OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD Be USED FOR LEGAL NOTIFICATIONS AND BILLING: 1-❑ if. Ill.❑ <br /> i <br /> t THIS FORK!HAS SEEN 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 /> i <br /> i LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT s -OPTIONAL 9UP111SOR-DISTRICT CODE -OPTIONAL <br /> 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM IB,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> i OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIW ES <br /> FOIi007M-R7 <br /> FO RM A(3`!a3) <br /> v v�:z j�lei S w� <br /> i d ' <br />