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'EgOUR09 C <br /> STATE OF CALIFORNIA Ar °a <br /> STATE WATER RESOURCES CONTROL BOARD s` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA W�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:j 7 PERMANENTLY CLOS <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 4Ip I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> rt <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 0 Ara-j12 el-11 arms w <br /> A E NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> w <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA '"' <br /> ✓BOX `-I�?`CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST_. <br /> TYPE OF BUSINESS 4. I'"1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN I*OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> In 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDSe. <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST FIRS PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARffA CODE NIGHTS: NAME ST,FIRST) PHONE#WITH AREA CODE <br /> — <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C)I= <br /> MAILING OR STREET ADDRESS ✓ box to indicate [ 'INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME' STATE ZIP CODE PHONE It WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ze��-- <br /> MXVAGbW9ffl;tEfWDR9SS ✓ box to indicate Q INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ]'CORPORATION [] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 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 ='11 SELF-INSURED 0 2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> = 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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: 1.0 II.a 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&SI TUBE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY' w <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(6-95) <br /> OWNER MUST FILE THIS FOR 'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR TORAGE TANK REGULATIONS <br /> y- 9 <br />