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�.Aa <br />STATE OF CALIFORWA <br />4x— <br />MARK <br />STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILRYISITE ONLY rO t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLYD SITE <br />ONE REM u 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION&ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA CODE <br />ADD Be <br />NEAREST CROSS STREET <br />PARCEL I(OPTONN) <br />T <br />PHONE A WITH AREA CODE <br />STATE <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE i WITH AREA CODE <br />T.CA <br />j, <br />T,/,BOXTE 71'.R;ORAnOsl 0 INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY 0 COUNTYAGENCY' D STATE-AGERCY' 0 FEDERAL AGENCY' <br />DISTRCTS' <br />' N owner of UST Is a pub9c agency, complete the following: nate of Supervisor of division. section, or Wlbe which operates the UST <br />TYPE OF BUSINESS 0 O GAS STATION 0 2 DISTRIBUTOR <br />O ✓ IF INDIAN <br />10 OF TANKS AT SITE <br />E. P. A. 1. D. i (4pliuW) <br />0 3 FARM 0 4 PROCESERVATION <br />ESSOR Q 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY MNTACT PERSON BSFCONnARY3. nv,H—.O <br />DAYS: NAME (LAST, FIRST) <br />PHONE i WITH AREA CODE <br />- <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA CODE <br />/" <br />NIGHTS: NAME T, FIRST) <br />PH NE WIT ARE <br />NIGHTS: NAME( .FIRST) <br />PHONE A WITH AREA CODE <br />STATE <br />II. PROPERTY OWNER INFORMATION - (MI1ST RF (:OMPI FTFM <br />NAME <br />CARE OF ADDRESS INFORMATION <br />zz <br />MAILING OR STREET ADDRESS <br />MAILMING OR STREET ADDRESS <br />✓ box b9dbsls 0 INDIVIDUAL (] LOCAL -AGENCY 0 STATE -AGENCY <br />' <br />O CORPORATION ID PARTNERSHIP O COUNTYAGENCY 0 FEDEFUUIGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE i WITH AREA CODE <br />C <br />111. TANK OWNER INFORMATION - (MIIST BE COMPI FTFM <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to rdkLs 0 INDIVIDUAL <br />O LOCAL -AGENCY E-1 STATE AGENCY <br />' <br />O CORPORATION O PARTNERSHIP <br />0 COUNTYAGENCY ED FEDERALAGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE i WITH AREA CODE <br />IV. NUAHU OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) Hp 4 4 - D <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ Eor biMicaN O 1 SELF-INSURED = 2 GUARANTEE O 3 INSURANCE O 4 SURETYBONO <br />0 5 LETTEROFCREDIT M a EXEMPTION 0 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: I. O IL Q IIL O <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LUL,AL AlAt NUT UJt UNLT <br />COUNTY x JURISDICTION t FACILITY! <br />® [-� 546-6 L17 IAP <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (T) OR MORE PERMIT APPLICATION • FORM B, UNLESS THIS IS A CHANGE OF SRM INFORMATION ONLV <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A 1393) FOR003MR7 <br />1512 <br />