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hp t <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH F ISRE <br /> ❑ t NEW PERMIT CD RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY 4-AM tPED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> ONE REM E] 2 INTE ''�C—1 _ <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETNDE of 99ERATOR <br /> nBA f3q T.wTY NAME <br /> d\ TCROSS TR ET PARCELI(OPfIONAu <br /> ADDRESS <br /> STATE ZIP CODE SITE PHONE#CW/ITH AREA CODE <br /> CITY N E i/ CA .s3 '- b <br /> C.LLa. <br /> ✓ BOX Q CORPORATION Q ply Q PARTNERSHIP Q Lam' Y Q the LIS AGENCY' Q STATE•AGENCY' Q FEDERALAGENCY <br /> ' <br /> TO INDICATEes <br /> I d#ner aLUST is a ub tlw iWowYnq:° of S rvYor of division.s#elbn of��'�..° NDUW #OF TANKS AT SITE E.P.A. I.D.#(apoonal) <br /> TY F BUSINESS Q t GAS STATION Q 2 DISTRIBUTORQ RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS:NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> DAYS: t�A E(LAST.FIRS PHONE#WITH AREA CODE <br /> / z,c 6 / NIGHTS:NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> PHONE WITH AREA <br /> NI : NAME T.FIRST) 0. 3- 'ZOO <br /> If. PROPERTY OW ER INFORMATION- MUST, BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME 1 Y <br /> OYyl iZg ��'www111 ✓ppxbMdicaM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q'FEDERAL-AGENCY <br /> -S STATE 7JP CODE P NF WITH ARES►CODE <br /> I CI NAMEAo� � �_ 6 7 <br /> III. TANK OWNER INFORMATION-(MU777];FR <br /> OMPLETED) S INFORMATION <br /> NAME OF OWNER <br /> S s✓V>✓�-- GQ INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> Q PARTNERSOIIP Q��NE#GWITH AREA CO FERAL-AGENCY <br /> IP CODE <br /> CITY NAME <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 `SURETY BOND <br /> Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q <br /> ✓ b ' Q 5 LETTER OF CREW Q 6 EXEMPTION Q II OTHER <br /> A. 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.❑ IL III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.W►ERUE ANDCORRECTFYJIR <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'S TITLE <br /> LOCAL AGENCY USE ONLY Z �? <br /> JURISDICTION# FACILITY i <br /> couNrrx ® 3 3 7 <br /> LOCATION CODE -OPTIONAL <br /> CENSUS TRACT •OPTIOAIAL SUPVISOR-DISTRICT CODE •OPTIONAL <br /> ) <br /> PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE ' ONLY. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL A090 IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNS <br /> FORM A(3fa3) <br />