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C46OVe � <br /> C , <br /> STATE OF CAUFJRNIA <br /> STATE WATER RESOURCES CONTROL BOARD aw8� a S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> j COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ❑ 7 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MAflKONLY <br /> 4 AMENDED PERMIT g TEMPORARY SITE CLOSURE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ ❑ <br /> I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED)NAME of OPERATOR <br /> DBA C)l FACILITY NAME <br /> �/ 7,T/, /�J �r (�•C) PARCEL#(OPfIONAL) <br /> � 6YREST CROSS STREET e, <br /> ADDRESS � ' '� STATE STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> CITY NAM CA <; - <br /> r <br /> li l <br /> ✓ Box LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY" O FEDERAL-AGENCY' <br /> TOINDICATE .CORPORATION O INDIVIDUAL O PARTNERSWP 0 DISTRICTS' <br /> II oaner of UST Is apubic agency.cunplete the following:named Supervisor of&Ision,section•or office which Operates <br /> the <br /> i OF TANKS AT SITE E.P.A. I.D.i(aplbnae <br /> IF IN <br /> TYPE OF BUSINESS [:j7 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACTPERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) <br /> PHONEi WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONEi WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> -- PHO NE i WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONEi WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> _ - c ✓ boxtllMkab INDIVIDUAL I] LOCAL-AGENCY ED STATE-AGENCY <br /> 1M91LI G OR STREET ADDRESS CI I CApPoRATION PARTNERSHIP 0 COUNTY-AGENCY l�FEDERAL-AGENCY <br /> -i ', f gTpTE� ZI DE PHONE i WITH AREA CODE <br /> CITU NA►IT: 1 CC p <' <br /> III. TANK OWNER INFORM ION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ box tlindkme (] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS _ <br /> �CORPORATION O PARTNFASWP E:3 COUNTY-AGENCY ONE iWITH ARE DEEML-AGENCY <br /> STATE ZIP CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -a� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF INSURED Q 2 GUARANTEE 1� 7 INSURANCE 0/SURETY BOND <br /> ✓box tlindkaN 5 LETTER OF CREDIT Q I EXEMPTION 0 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 /> D BILLING: <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD 8E USED FOR LEGAL NOTIFICATIONS ANI.❑ I. III'❑ <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'STITLE DATE MONTWDAVIVEAR <br /> LOCAL AGENCY USE ONLY <br /> C.�OUNGT��#Y <br /> JURISDICTION <br /> �# FACILITY <br /> `�—�^—�-v� <br /> LOCATK)N -OPTIONAL CENSUS TRACTiTK1NAL <br /> SUPVISOR-DISTRICT CODE 'OPTIONAL <br /> J /1 ()n(0) z - :1 <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 FOR00e3AA7 <br /> FORM A(3193) • • <br />