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STATE OFCAUFORNA <br /> C/ STATE WATER RESOURCES CONTROL BOARD c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE ` 0 <br /> MARK ONLY ❑ 1 NEW PERMIT c��"OeM�- <br /> ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION SED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT 7 PEflMAN <br /> ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY ITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> nRn OR FACILITY NAME <br /> I NAME OF OPERATOR <br /> FADDRESS F <br /> NEAREST CROSS STREET PARCELe(OprIONAN <br /> ESTATE ZIP CODEONE#WITH AREA COPE <br /> oxCA d ATE O CORPORAFTION QUAL ED PARTNERSIYP Q LOCAL-AGENCY <br /> N Omer Of UST b a public agency,WMPWe the forowbg:name Of Superviapr of eNlebn,section.or MOD which O�UNfy-AGENCY• OSTATE-AGENCY• O FEDEML#GENCY <br /> TYPE 0. BUSINESS ❑ ❑ operates the UST <br /> t GAS STATION 2 DISTRIBUTOR ❑ ✓ R INDIAN J' <br /> OF TANKS AT SITE E.P.A. I.D.0 Idpk�V <br /> ❑ 3 FARM ❑ e PROCESSOR [-6 OTHER RESERVATION <br /> OR TRUST LANpS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-6ptfon3l <br /> DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NN9HTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS:NAME(VST,FIRST) <br /> PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> np n CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓b wln9eab L_J INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION = PARTNERSMP I=COUNTYAGENCY Q FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE <br /> PHONE a WITH AREA CODE <br /> III. TANKOWNER INFORMATION•(MUSTBECOMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAIL#IGORSTREETADDRESS ✓ bwbNdCsN Q INDIVIDUAL = LOCAL-AGENCY Q STATE AGENCY <br /> O CORPORATION Q PARTNERSIIIP =COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CIT'NAME STATE 21P 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ecv 10 Mites Q 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE D I SURETY BOND <br /> 5 LETTEROFCREDIT O 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERSTDLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CWN[Y# JURISDICTION# FACILITY# <br /> II' <br /> LOCATION CODE -OPTIONAL CE TIr TIONAL BUPVISOR-DISTRK:T CODE OPTIONAL <br /> z . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3N3) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE <br /> TANK REGULATIONS <br /> FOR0039AA7 <br /> � lY <br />