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`6Wo <br /> w <br /> STATE OF CALIFORNIA ' 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR <br /> ry o <br /> COMPLETE THIS FORM FOR EACH YISITE / `'r�•a "'• <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMAN 0 SIT <br /> ONE REM (� 2 INTERIM PERMIT Q A AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRAORFACILITY NP.ME j NAME OF OPERATOR / <br /> S ' M EARESTCROSTREEPM LA \O <br /> —ADORES l <br /> CIN NAME STATE ZIP ODE / - SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ <br /> BOX INDIVIDUAL CORPORATION (] INDNIOUAL Q PARTNERSHIP LOCAL-AGENCY 0 DISTRICTS' COUNTY-AGENCY O STATE-AGENCY* FEDERAL-AGENCY' <br /> II owner d UST is a public agency,cooplele Ne following:narne of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN <br /> #OF TANKS AT SITE E.P.A I.0.#(Whonal) <br /> Q 3 FARM Q a PROCESSOR Q 5 OTHER OR TRUST LANDS <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. S PHONE a WITH 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 ✓ Lor bindicate 0 INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> Cil. NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS .1babimeals INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 11 =CORPORATION Q PARTNERSHIP O COUNTY AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGEFEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HCI4 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa binckaw I=1 SELF-INSURED I=2 GUARANTEE IED 3 INSURANCE 0 a SURETY BOND <br /> =5 LETTER OF CREDIT I=a EXEMPTION 099 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> pWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWOAY/V R <br /> r <br /> �o <br /> LOCAL AGENCY USE ONLY , J <br /> COUNTYx JURISDICTI NM i FACT a yC <br /> T j <br /> LOCATION CODE -OPThONAL (CENSUS TRACT# - TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL n <br /> 12 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 FOREjp THE LOCAL AGENCY IMPLEMENTING.THE UNDERGROU "RAGE TAN EGULATO—•M-7� <br /> FORM A(393) f „ ''7 J C7 ! FOR=3Afl1 <br />