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eke <br /> f <br /> t.,°UNClS <br /> } STATE OF CALIFORNIA <br /> ;§ STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT + <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �t <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N r NAME OF OPERATOR <br /> CIAOl� V�CL ��JC <br /> s. <br /> ADqRtSS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> (4Lkx-> (AJIk.) <br /> 81 <br /> CITY NAM.E� STATE ZIP C0 a TC.� <br /> ODE <br /> A / (ONE#WITH AREA C <br /> ✓BOXCORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE•AGENCY' FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> M owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> s TYPE OF BUSINESS ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> t` 1 GAS STATION 2 DISTRIBUTOR ❑ <br /> RESERVATION mR' <br /> ❑ 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS t <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: IJAME(LA T,FIRST) <br /> PHONE#'TH�t�';(I S DAYS: HIVE(LAST,FIRS I �r�E� REA CODE <br /> as MF7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> .fi3A- M i <br />' II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> le' �CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> Ir CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> f, III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME JSTATE ZIP 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 [4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY RerJ D A31 7&1P <br /> COUNTY# JURISDICTION# FACILITY# <br /> E — <br /> LOCATIO O, OPTIONAL CENSUS T I/lTT# • NAL SUPVISOR�ST 3 CO OPTIONAL <br /> °o (w..�l i✓S r �J/V�7ar <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 FORN�THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO RAGE TANK REGULATIONS <br /> FORMA(6-95) <br />