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Af <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> y COMPLETE THIS FORM FOR EACH FAGLITYISITE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT Q 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 < AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE �Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NAME <br /> //.�.�� NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL I(OPrIONAL) <br /> 3o s. G ,E mos <br /> CITY LSTATE ZIP CODE SITE PHONE i W ITH AREA CODE opL CA �iliZ�IO <br /> r 1NOCAI <br /> 0E O CORPORATION EkINDIVIDUAL O PARTNERSHIP LOCAL-AGENCY E-3 COUNTYAGENCY' ED SrATE-AGENCY' O FEDERALAGEWY' <br /> 'It owner of UST Is a public agency,corriPlete the IOBoWn :name of S DISTRICTS' <br /> B upervkor of oNkbn,eeciion,or on m which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN i OF TAN AT SITE E.P.A I.D.i(apflanal) <br /> = 3 FARM Q d PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> G «v v� 3 r <br /> N 9: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME( FIRST) PHONE i WITH AREA CODE <br /> .Sas La Z�) 333- <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME .QS T CARE OF ADDRESS INFORMATION <br /> QJ�AiE <br /> MAILING OR STREET ADDRESS ✓ busbbtlkm 0INWVIDUAL LOCALAGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> AHE -7- <br /> MAILING <br /> MAILING OR STREET ADDRESS ✓ boa bMICIUM O INDIVIDUAL LOCAL AGENCY (] STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP ED COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STg7E ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bur b 0 1 SELF-INSURED L-1 2 GUARANTEE 5 INSURANCE 0 A SURETY BONG <br /> O 5 LETTER OF CREW O a E7EMPTION Q IS 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.� III. <br /> TMS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TRLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY st JURISDICTION i FACILITY <br /> 2� <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SLPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 L Z3. 90 1 3Lo <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(1193) OWNER <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL'jTKk13 <br /> FOROM -R7 <br />