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- � 6Wp C <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD .�.,�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �°.�„o.r�� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELa(OWgNAU <br /> CITY <br /> NAME STATE <br /> CA 21P CODE 917E PHONE a WITH AREA CODE <br /> TO INDICATE O CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDEIULAGENCY' <br /> DISTRICTS' <br /> X owner of UST Is a public agency,mrtplele the lotowing:name of Supervisor of ONMiun,section,or office whbh operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(opfAmmQ <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> E ERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAM (LAST.FIRST) HONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> leo ,PAvLE-1-f� <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �. /. CARE OF ADDRESS INFORMATION <br /> /'T�A�T /✓5'i4/1 it3Ti A <br /> MAILING OR STREET ADDRESS ✓ box bindbale = INDIVIDUAL =1 LOCAL-AGENCYl�STATE-AGENCY <br /> A Lj CORPORATION = PARTNERSHIP CWMYAGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 4iL Zq^2Q <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATIO <br /> Sc�(i/Foy /L Lq0 ALIC-e <br /> MAILING OR STREET ADDRESS ✓ bot bin0lNti Q INDIVIDUAL LOCAL-AGENCY 17:1 STATE AGENCY <br /> 95-17 =CORPORATION ] PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGEWY <br /> CITY NAMM.E�APO�� STATE ZIP CODE PHONE a WITH AREA CODE <br /> " "/ TO �/ Z / Z - <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. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓bcbYdksY O I SELF INSURED 2 GUARANTEE 0 3 INSURANCE E--j 4 SURETY BOND <br /> 5 LETTER OF CREDIT O B EXEMPTION Q 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 /> C14ECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.�4 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u JURISDICTION a FACILITY a <br /> D 0 �y9�gd <br /> LOCATION CODE -OPTIONAL CENSUS!0g T�L OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> J 34OR <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 UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR0033A1i7 <br />