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.o <br /> STATE OF CALIFORMA � <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED RE <br /> O 1 NEW PERMIT � 3 RENEWAL PERMIT Q <br /> MARK ONLYa TEMPORARY SITE CLOSURE /J <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT <br /> 1. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED)AME of OPERATOR <br /> rXiA OR FACILITY NAME <br /> —A14 `' NEAREST CROSS STREET PARCEL I(OPTIONAL) <br /> ADDRESS�6 <br /> IA�YLRfO- STATE /Z`I`PSCODE77 <br /> I., SITE -110?NEa WITTY AREAyC/Oy—DE/ <br /> CITY NAMECA 9 W� <br /> 4942r <br /> I/ O CORPORATION RPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY (]COUNTYAGENCY' STATEdGENCY' O FEDERAL#GENCY' <br /> TOINgCATE DISTRICTS' <br /> •N ownw of UST Is a public agency.mnplste the tolowbg:nar of Supervisor of oivMbn.section,or orrice which opsrate I the UST <br /> O i GASSTATION 2 DISTRIBUTOR Q ✓ IRVATION sOF TANKS AT SITE E.P.0. I.D.a(opllorul) <br /> TYPEOFBUSINESS <br /> Q RESERVATION <br /> Q 3 FARM Q e PROCESSOR k <br /> 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) <br /> PHONEY WITHAREA CODE DAYS: NAME(LAST.. PHONE i WITH AREACOOE <br /> NIGHTS: NAME(LAST.FIRST) <br /> PHONE/WITH AREA CODE NN31iT3: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME/ /{��, _ <br /> 4 `� �r ��� ✓bo[blMbaN �INDIVIDUAL OLOCAL-AGENCY �STATE AGENCY <br /> MAILING OR STREET ADDRESS <br /> _ CORPORATION PARTNERSHIP 0 COUNfY-AGENCY FEDERAL-AGENCY <br /> STATE 21P CODE P E e WITH AREA CODE <br /> CITY ME CPA-7z.1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER tU� S INFORMATION <br /> vGMAILING OR STREET ADDRESS O INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> PMTNFASHIP COUMY-AGENCY 0 FEOERAIdGENCY <br /> CITY NAME CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION�UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- -FT-I I I I J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ba bindkaM O 1 SELF-INSURED =2 GUARANTEE 0 3INSURANCE O A SURETY BOND <br /> O 5 LETTEROFCREW 06 EXEMPTION O 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: L O ll. 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 5 SIGNED) OWNERS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTKNI# FACILfTY t <br /> LOCATION CODE -OPTIONAL CENSUS TR_L # -OPTIONAL SUPVISOR-DISTRICT CODE -OP770ML <br /> C� a � aZv <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE III1FORmATmDm ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR003311,417 <br />