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• yyOJ- [ <br /> STATEOFCAUPORNIA `ff ..•,• yo <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ,r <br /> [fit VU1.M'f <br /> COMPLETE THIS FORM FOR EACH FAdLITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT O S CHANGE OF INFORMATN7N, PERMANENTLY CLOSED SIT <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT I] S TEMPORARY SITE CLOSURE <br /> I. FACILfTY/SITE INFORMATION dt1lU (MUST BE COMPLETED) <br /> DBAORFACILITYN E NAME OF OPEM R <br /> • Q �PARCEL$IO <br /> ADDRE / NEARESTC STREET FTIONAU <br /> t <br /> CITU NAME STATE ZIP CODE SITE PHONE$WITH AREA CODE <br /> CA — <br /> TOIN Box O CORPOPATC1I O INDIVIDUAL O PARTNERSHIP O AGENCY 0 COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> 'If own#of UST Is a Pubic agencY.oomPleta the folowh g:named Supervisor oldIvIsIm seclbn,cr oNice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORflE/ IF IN ION sOF TANKS AT SITE E.P.A I.1 (aplbWl 9 <br /> Q 3 FARM 4 PROCESSOR OTHER I ORTRUSTUIFIDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N ME(LAST,FIRST) / PHONE i WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> qD S / // _ <br /> NIGH : NAME T, ST) PHONE$WITH AREA CODE NIGHT : NAME(LAS .FI PHO E s WITH AREA CODE <br /> �vP _ U ZD - S/ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM E OF ADDRESS INFORMATION <br /> 5 e, <br /> MAILING @P4STREET ADDRESS blMkas INDIVIDUAL 29 LOCAL-AGENCY L—I STATE-AGENCY <br /> zlE O CORPORATION O PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N E STATE ZIP CODE PHONE$WITH AREA CODE <br /> �S,zO Z 9.5"z9,3 2- z5v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED OwR CA EOF DDRESS INFORMATION <br /> MAILING O REETADDRESS ✓boxbUbcats INDIVIDUAL OCAL-AGENCY O STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP O COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAM ST ZIP CODE PHONE i WITH AREA CODE <br /> T� 20 <br /> IV.BOARD OF EOUA IZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO ®- <br /> V. PETROLEl1M3 iT FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b4lsbW Q 1 SELF-INSURED O 2 GUARANTEE ED 3 INSURANCE (]4 SURETY BOND <br /> D 5 LETTER OF CREDIT O S EXEMPTION O 90 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 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER NAMEyI(.PRCINTE 651G O) OWNERST DATE /MONT Y/Y R <br /> ✓ c� !o �� <br /> L AL AGENCY USE ONLY,4 , -{per G 1 ,6 <br /> COUNTY# JURI DICTNDNa FACILITY• <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT$ -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> i <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 FORN""TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO'"""ISTORAGE TANK REGULATIONS 2L, vd 3A <br /> FORM A(3193) <br /> c23- y7 -`r� � � _i -9 � <br />