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- �cSJ•• f C <br /> STATE OFCALIFOR.MAAt <br /> /N STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM <br /> COMPLETE THIS FORM FOR EACH FACILIYYfSrrE <br /> MARK ONLY ❑ I NEW PERMIT ❑ S RENEWALI PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY 517E CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> 08A OR FACtLITY NAME NAME OF OPERATOR <br /> ADDRESS I NEAREST CROSS STREET PARCEL r(OPTIONAL) <br /> TP^ P51 fJ2� 2� {'c Ste` <br /> CITY NAME STATE ZIP COOE3 SITE PHONE 11 WITH AREA CODE <br /> CA <br /> ✓ BoxORPORATION NDIVTUAL = PARTNERSHIP Q LOCAL-AGENCY []COUNTY-AGENCY QSTATS-AGENCY [� FEDERAL-AGENCYTO INDICATE DISTRICTS <br /> TYPE OF BUSINESS s GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN o OF TANKS AT SITE E.P.A. L D.s r4*6c0a1) <br /> ❑ I RESERVA710N <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON {PRIMARY} EMERGENCY CONTACT PERSON (SECONDARY)•optional 0 <br /> DAYS: NAME{LAS ,FIRST) P14ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 91U o—r `7 0 , <br /> NIGHTS: N ME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON;z WITH APE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME t CARE OF ADDRESS INFORMATION <br /> .i. WCgsoj <br /> ,MAILI R STREET ADORESS ✓ box kala INDIVIDUAL Q LOCAL-AGENCY G STATE-AGFNCY <br /> O B L CORPORATSON PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYNA STATE ZIP CODE II PHONE#WITH AREA CODE ;P <br /> t o, o <br /> Ill. TANK OWNER INFORMATIO -(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS INDtVIOUAL LOCAL-AGENCY STATE•AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY [' FEOERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br />{ i <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> t TY(TK) HQ F4-F4-1-1 6131 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—.IDENTIFY THE METHOD(S) USED <br /> r ✓box n indkala [] 1 SELFINSURE0 ©2 ARANTEE Q 3 INSURANCE ©4 SURETY BOND <br /> S LEFfEROFCREDIF y. dEXEMPTION 99 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 SOX 3NMCATIN13 WHICH ABOVE ADO RESS SHOULD BE USED F81 LEGAL NOTIFICATIONS AND BILLING: I_❑ R.❑ III.❑ <br /> L. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PAIN TED&SIGNATURE) APPLICANTS TiTLE DATE MONTWDAYNEAA <br /> LOCAL AGENCY USE ONLY <br /> i e-Ii; <br /> COUNTY# JURISDICTION# FACILITY# � -�/ <br /> . ._. � b z /`� <br /> E <br /> LOCATION CODE -OPT1pNAL CENSUS TRACT OPT"CNAL f SUPVISOR•DISTRICT CODE -OP170NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PE=RMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIOkONLY. <br /> PC RM A(5-91) FCR=3A-5 <br /> \ r <br />