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<y0U- <br /> � STATE OF CALIFORNIA }w o <br /> STATE WATER RESOURCES CONTROL BOARD `- <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ,may <br /> 1 <br /> MARK ONLY O T NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO S <br /> ONE ITEM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> �. <br /> ORA OR FACILITYNAME NAME OF WI,KATO! .. <br /> - �PARCEL#(OPTKINAU <br /> ADDRESS NEAREST CRO55 STREEF <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> q <br /> ✓ Box Ly]CORPORATION INDIVIDUAL ID PARTNERSHIP � LOCAL-AGENCY COUKrY.AGENCY' STATE-AGENCY' ED FEDERAL <br /> TOINDICATE -DISTRICTS' <br /> I owner cl UST is a pdblic agency,corrplete the following:name of Supervkur of division,section,m o5ica which operates the UST — <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.•(tplImal/ <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR- .0 5 OTHER OR TRUST LANDB <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Y <br /> NIGHTS' NAME(LASE FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRS1) PHONE#WITHAREACODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION " <br /> MAILINGOR STREET ADDRESS ✓ bIndicate [] INDIVIDUAL O LOCAL AGENCY (] STATE-AGENCY <br /> K ( / J CORPORATION 0 PARTNERSHIP O COUNTYAGENCY E:1 FEDEMLAMWY <br /> CIT NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AD7RESSIIN`FORMATION / <br /> MAILING OR STREETADDRESS ✓ Wxbmcaia O INDIVIDUAL E-1 LOCAL-AGENCY D STATE AGENCY <br /> [Z:?tORPORATION E-1 PARTNERSHIP D COUNTY-AGENCY O F6BERAL-AGENCY <br /> CITY NAME STATE ' ZIP CODE - PHONE#WITH AREA CODE <br /> � / . - `ff <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44 -I ` I - 1 . 1 ' II II <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ D.110 = 1 SELF-INSURED E-1 2 GUARANTEE d 3 INSURANCE (]4 SURETY BOND <br /> E�] 5 LETTER OF CREPT O 6 EXEMPTION W 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.Q it.O HE <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE R'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTHUDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION x FACILITY# <br /> I <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# OPTIONAL 9UPVISOR-DISTRICT CODE -OP77ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS TNIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) <br /> FOROD33A437 <br />