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STATE OFCALIFORLA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISRE <br /> NARK ONLY O 1 NEW PERMIT Q 3 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SIT <br /> ONE REM <br /> Q2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMAT ON&ADDRESS-(MUST BE COMPLETED) <br /> DBA OFJ FACILITY NAME NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> Z00S . <br /> CITY NAME STATE ZIP CODE 917E PHONE i W LTH AREA CODE <br /> ZoQz CA 9 <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' Q STATE-AGENCY' O FEDERAL AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a pubic agency,ow plate the following:name of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN nOF TANKS AT SITE E.P.0. I.D.•(apNerWl <br /> 3 FARM 4 PROCESSOfl 8 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCI CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <br /> DAYS: N E(LAST. IRS HONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> tit 3 - <br /> NIGHTS: NAME(LAST.FIRST) HONE a WITH AREA COD NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> 11. PROPERTY OWNEINFOR ATION- MUST BE COMPLETED <br /> FUME CARE OF ADDRESS INFORMATION <br /> Y <br /> MAILING OR STREET ADDRESS ✓boa b ln6bn INDIVIDUAL E::] MAL-AGENCY ED STATE.AGENCY <br /> M CORPORATION PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CIE STATE ZIP CODE P ONE i VfTH AREA CODE <br /> •LT �/ Z� �-733 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N EO OWNER CARE OF ADDRESS INFORMATION <br /> MAILING RSTPEET ADD ESS ✓bol bkdkm INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Zb�2 �t✓ O CORPORATION PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> Cm NAME r STA ZIP CODE I I E iV1�TF{IAR�EAA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bp,64MkaY t SELF-INSURED 11 2 GUARANTEE 3 INSURANCE 0 A SURETYBOND <br /> 5 LETTEROFCREDIT O 6 EXEMPTION D 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. 111.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C6RRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MOfNTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION FACILITY• �- <br /> qi�� <br /> L CODE-OPTIONAL CENSUSTRACTa -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL. h <br /> Z3. <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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN^"TORAGE TANK REGULATIONS <br /> FORMA 1393) FOf10D3NA7 <br />