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* ■ e <br /> d'C edeesa <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMS <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 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 a(OPTX)NAL) <br /> � f-�Ir +7 <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> V BOX 4N-CORPORATION 0 INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY F__1 COUNTY-AGENCY' (�STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> °9 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 1 GAS STATION Q 2 DISTRIBUTOR = <br /> RESERVATION <br /> INDDIAN a OF TANKS AT SITE E.P.A. 1.D.a(optional) <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> sre(A/ - 2-73-`7 -7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C_1 rN <br /> MAILING OR STREET ADDRESS ✓box bindirate 0 INDIVIDUAL LOCAL-AGENCY =STATE-AGENCY <br /> If " ^ CORPORATION (]PARTNERSHIP F-1 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P PHONE a WITH AREA CODE <br /> 'T -5- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> E <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL (] LOCAL-AGENCY ED STATE-AGENCY <br /> =CORPORATION PARTNERSHIP O COUNTY-AGENCY O 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 M44- -1®I e I 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bMieat® 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT 6 EXEMPTION (]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. III.El <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(PRINTED8 NED) i f�l�l� OWNER'S TITLE DATE TW YNEAR <br /> 22 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m F <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE -OPnOML <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLK:AT - FORM B,UNLESSTHIS IS A CHANGE OF SITE INFIORMATION ONLY. <br /> FORMA(3/83) OWNER MUST FILE THIS FOR WITH THE LOCAL AGENCY IMPLEMENTING ND THE UNDERGR STORAGE TANK REGULA <br /> di7 <br />