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w•n. <br /> � STATE oFcwFORMA <br /> STATE WATER RESOURCES CONTROL BOARD 40�� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM A , , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �""°"M��' <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT F-15 CHANGE OF INFORMATION O 7 PERMANENTLY <br /> ONE REM F-1 2 INTERIM PERMIT F 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITY AAE n / NAME OF OPERATOR <br /> FTO <br /> RESS I'L Qi J-M-FZtVX�/.�✓Ai— NEAREST C OSS STREET PARCEL#(OPTIONAL) <br /> NAM STA ZW SITE PHONE a WITH AREA CO <br /> CA S Zo b z, uz� <br /> EBOXGATE QCORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNry-AGENGV' Q STATE.AGFACY' Q FEDERA-AGENCY' <br /> DISTRICTS' <br /> • <br /> IT owner of UST Is a pubis agency.mWIMe the following:name of Supemisor of division,section.or office which operates fie UST <br /> IF I <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR q SERVADTION IAN a OF TANKS AT SITE E.P.0. I.D.#/aptbrap <br /> 0 3 FARM 0 4 PROCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> r <br /> YS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> GHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Dos bNdlcsls Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br /> Q CORPORAPON Q PARTNERSHIP Q COUNrV-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ijo�ygr <br /> MAILING OR ITREET ADDRESS ✓ Eu.N ndscm Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Ile,10 Z44/ <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATEZIP 3E PHONE a WITH AREA CODE <br /> d/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)32 -9669 i questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eor binAicab Q 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 E*MFTKON Q 29 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication 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: 1.Q IT.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 S SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION is FACILITY a <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORTA&TION U, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOROOSMAU <br />