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3 i <br /> !� <br /> STATE OF CAUFOFNA .e <br /> STATE WATER RESOURCES CONTROL BOARD ; e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ARK ONLY 9 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT Q O TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION -( ) <br /> DBA OR FACILITY N NAME OF OPERATOR <br /> ADD FS NEAREST CROSS STREET PARCEL#(OPTIONAL)'- <br /> a <br /> CITY NAME STATE ZIP p SITE PHONE#WITH AREA CODE <br /> C <br /> Box <br /> TO INDICATE CORPORATION Q INDIVIDUAL ®PARTNERSHIP ® LOCAL-AGENCY Q COUNTY-AGENCY° Q STATE-AGENCY' Q 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 t GAS STATION 2 DISTRIBUTOR ® ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. 1.D.#(optianal) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> D :NAVE(LAST,FIRST) PHO <br /> NE#WI H AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) ® P14ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- UST BE COMPLETED) <br /> N E eo_ 0 CARE OF ADDRESS INFORMATION <br /> MAILI G OR STREET ADDR SS ✓box b Uxfieate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> r Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY" <br /> CITY NAMEy ST TE ZIP OD PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box ioindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATIONUST ST FEE ACCO T U -Call(916)322-9669 if qU Go s arisg. <br /> TY K) H M44- - 11 ® 1 a a d< <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY• &S BE C ET )-IDENTIFY THE METHODS) USED <br /> ✓W.b micste Q I SELF-INSURED 2 GUARANTE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> I. LEGAL NOTIFICATION AND BILLINGLegal 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: L= 11.El III.a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICT # FACILITY# <br /> 3j 1 <br /> 7 101-613-F6_19[71 <br /> LOCATION CODE -OPTIO CENSUS TRACT# • TIO S TROT. OP <br /> e�f <br /> THIS FORg MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER - FORM B,UNLESS THIS IS A 64ANdF 09 SITE INFORMATION ONLY. <br /> E T FI T FOR E L I UNDERGROUND STORAGE T R ULA <br /> FORMA( ) 3A-Rr <br />