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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W mom° o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE c•L�oRN`' <br /> MARK ONLY ? NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM D 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> - t <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Nit CA <br /> ✓ Box ` <br /> TO INDICATE ¢SL CORPORATION Imo'INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY <br /> 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 O 1 GAS STATION 0 2 DISTRIBUTOR = ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q'15 OTHER OR TRUST LANDS <br /> t <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSn PHONE#WITH AREA CODE DAYS: NAME r`r FIRST) PHONE WITH AREA CODE <br /> 53 7_07W <br /> NIGHTS: NAME(LAST,FIRPHONE# H AREA CODE NIGHTS:NAM (LA�R -- PHONE#WIREA CODESY' <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> 447 <br /> NAME . CARE OF ADDRESS INFORMATION <br /> 5TFo r- 1 E L� = <br /> ?;.� MAILING OR STREET ADDRESS ✓box b indicate =INDIVIDUAL Q LOCAL-AGENCY �STATE-AGENCY <br /> , 0 , /n(o Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> - CITY NAME ST TE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) odly <br />} NAME OF OWNER ` CARE OF ADDRESS INFORMATION <br /> MAI ING TREET ADORE 3 /wv) ✓ box b indicats [9 INDIVIDUAL � LOCAL-AGENCY Q STATE-AGENCY <br /> 1/yez �j D CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> r <br /> GITV NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> G <br /> IV BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> (TK) HQ4 41101- - b <br /> i <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> E <br /> box IDindicate El 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION 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 /> rC7HE'KONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. <br /> THIS FOR SBE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME( INTEO -_IGNED) S I 'F j` F 7-0 OWNE ' TITLE DATE MONTWDAYIYEAR <br /> ✓. 75 <br /> ' 1 <br /> W AG USE ONLY <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FOR0033A•R7 <br />