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s <br /> -aoa. <br /> STATEOFCAUFIDRMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A z s <br /> COMPLETE THIS FORM FOR EACHfACILITYISITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT IT15 CHANGE OF INFORMATION O PERMANENIZTLX.CLPSED SITE <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITY/SITE INFORMATION&ADDR -(MUST BE COMPLETED) <br /> DBA OR FACIL TY N E �V`' Alt NAME OF OPERATOR <br /> ADDRESS V 1" NEAREST ST PMCEL#(OFnONAU <br /> CITY NAME STATE ZIP CODE SITE P NE A WITH 11E <br /> CAIW%W 6 — 3Z <br /> TO.1 Box <br /> INOCATE (]CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY I1 COUNTY-AGENCYSTATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner clUST Is a public agency,ronplete the follvxing:ruune of Supervkor of dl isbn,sea office whbh operates the UST <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN 19OF TANKS AT SITE P.A. I.0.i(aplbnW) <br /> 3 FARM 4 PROCESSOR TNER OR RESERVATION TRUST LANDS <br /> / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> F1\L_1 NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 1' NAME CARE OF ADDRESS INFORMATION <br /> (A\\' MAILING OR STREET ADDRESS ✓bDXbk&sa D INDIVIDUAL LOCALAGENCY STATE-AGENCY <br /> 1\V1\e 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> I#. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> AME OF OWNER CARE OF ADDRESS INFORMATION <br /> \ MAILING OR STREET ADDRESS ✓ box bbtlkLs INDIVIDUAL LOCAL-AGENCY []STATE-AGENCY <br /> N\ CORPORATION PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA 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 /> ✓boxbMlcW 0 I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION (]W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 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 NAM E(PRINTED&SIGNED) OWNER'S TITLE DATE MONT A <br /> Y <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a �► / JURISDICTION �F7ACILfrvr <br /> LOCATIO DE -OPTIONAL CENSUS T TIONAL 9UPVI OR DISTRICT CODE -OPTIONAL / - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR Br UNLESS THS IS A CHANGE OF SITE INF R!NATION OM-Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOROm3AA] <br />