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• • <br /> STATE OFCAUFORNIA .` <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA .�� <br /> .. ,. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ' �.t,•oa„,- <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 0 7 PERMANENTLY D SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE / <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) / <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> IflV/� <br /> ADDRESS �. NEAREST CRO STREET C PAgCEL#(OPfxlNpq <br /> A <br /> CITY NAME STATE ZIP DE SITE PHONE WITH AREA CODE <br /> ✓ BOX a <br /> TOINDC0.TE O CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> It owner of UST Is a public agency,conolete the following:name of Supervisor of division,section.ISTRICTS- <br /> or Office which <br /> operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR v1IF INDIAN #OF TANKS ATSITE E.P.A. I.D.M(cplMnalJ <br /> 3 FARM O 4 PROCESSOR 5 OTHER RESERVATION <br /> rK OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NE#WIT AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE7] <br /> a 13 877-,5A 6 <br /> NIGHTS: NAME(LAST. IRST) Ea WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ horbinecab 0INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE is WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bot b Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ r4T4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindcale O t SELF-INSURED 0 2 GUARANTEE 3 INSURANCE <br /> D 5 LETTER OF CREDIT 0 S EXEMPTION D gb OTHER O<SURETY SONO <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: 1.0 It.[—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TfTLEDATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY [ C/ <br /> QC��OODUNc�TTY/�# JURISDICTION# FACILITY 0 <br /> a�? <br /> LOCATIONCODE -OP77ONAL CENSUS TRACT# -OPTIONAL <br /> �� SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ! �U <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 /> FORM q(393) THE UNDERGROUND STORAGE TA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING NK REGULATIONS <br /> /y? <br /> • 2�/ ✓ I f � FOROW3AR7 <br /> 75111 <br />