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A <br /> STATEOFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATK3N 7 PERMA NTLY CLOSED S <br /> ONE REM ❑ 2 INTERIM PERMIT O < AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> K M I-flGK- <br /> ADDRESS ���� ^ T�rSv I (o I W, NEAREST CR OSS STREET PARCEL a(OPTONAL) <br /> CITY NAME l//V, STATE 21P CODE SITE PHONE#WITH AREA CODE <br /> Box ca !1)—,3 7 <br /> ✓ <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARINERSHIP (]LOCAL-AGENCY (D COUNTY#GENCY 0STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 3 GAS STATION O 2 DISTRIBUTOR / O ✓ If INDIAN A OF TANKS AT SITE E.P.A. I. .#(xpli�slJ <br /> Lr({d/ RESERVATION <br /> 3 FARM O A PROCESSOR 6 OTHER pq TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREAST MRS <br /> D YS: NA E(LASju�za i o y <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA COOL IGHTS: NA (LAST,FIRST) <br /> PwnNp 2 WITH APPA COOP <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbbtlka4 INDNIDUAL LOCAL-AGENCY l] STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP Q COUNTY AGENCY O FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindkau INDIVIDUAL LOCAL-AGENCY 0 STATEAGENCY <br /> I=CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDEML#GENCY <br /> CITY NAME _ STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER -Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0inEkaN O I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q I SURETY SOND <br /> E__I 5 LETTER OF CREDIT E__I 6 EXEMPTION CJ 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.[-] IL O U. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAM E(PR IN TED N S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> s— 3 <br /> LOCAL AGENCY USE ONLY (N/ <br /> COUNTY# 4 �Jj JURISDICTION# FACIL�ITYj#-}��'-��J�� ���� <br /> -oCATIDN CODE OPTIONAL CENSU TgACT#�OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z_17 r O <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 /> FORM A(129T) FILE THIS FORMWITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAT NS <br /> FORom3A-R6 <br />