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t� Ve <br /> STATE OF CALIFORNIA <br /> .sr ,�' <br /> STATE WATER RESOURCES CONTROL BOARD A.,fir <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `����oer" <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br /> ONE ITEM Q 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ITYNAMENAME OF OPERATOR <br /> V_4.44_ i AAA elga4 <br /> ADDRESS NEARPT CROSS STREET PARCEL#(OPrIONAL) <br /> CITY NAME STATE 21PclCO•�SDE SITE PHONE 0 WITH AREA CODE <br /> CA 57.0 S�3 Z.1 Box / <br /> TOINDICATE CeCORPORATION IQ INDIVIDUAL IQ PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY' Q STATE-AGENCY' =FEDERALAGENCY' <br /> DISTRICTS' <br /> I owner d UST M a P. open ,mrrWde the fdlawing:name W Supervisor of d"don,section,or dlice which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.D.a(opfAAue <br /> ATION <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TTRUSTVLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY§ NAME(LAST,FLfiST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> J-3 <br /> NIGHTS: NA (LAST,FIR T) PHONE 0WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> s7_ s- o <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREEIr ADDRESS �✓ Lox binEicab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ImoCORPORATION Q PARTNERSHIP Q COUNTY#GENCY Q FEDERALAGENCY <br /> CITYAME STATE 21P CODE PHONE a WITH AREA CODE <br /> 'tea 6s - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEDFOWNER �� CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR STREET ADDRESS ✓ lox bintlbLa Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE 21P CODE PHONE*WITH AREA CODE <br /> IV.BOARD OF EOUALIZA71ON UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO 4 4- 0 2 O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx biMkaie IQ 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> IQ 5 LETTEROFCREDIT Q 8 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notifiration 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 II.O III. <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(PRINTED B SIGNED) OWNER'S TITLE DATE MOfNTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION JURISDICTION a FACILITY t <br /> ar <br /> TTTMON CODE <br /> ``''-OPTIDAML CENSUS TRACT a -OPTIONAL -DISTRICT CODE -CPTIONAL <br /> 7II/ O� 0— / <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 /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKIN6 <br /> /�FGflOMIIAT <br />