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�� ! � `ION• C <br /> ' - STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `ffi e o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A . s <br /> ' COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 0 2 INTERIM PERMIT ED A AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF ERATOR <br /> ADD S NEAREST C�STREET PARCEL 8(OFT001) <br /> S. r A <br /> CITY NAME STATE ZIP CODE' TE NE i WITH AREA CODE <br /> CA d (ea0 6- <br /> .1 Box CUY-AGENCY' <br /> TOINOCATE O CORPORATION INDIVIDUAL O PARTNERSHIP � 1 STATE-AGENCY' O FEDERALAGENCY' <br /> •I owner d UST Is a pudic agency.complete the following:name of Supervisor of dNMbn,sectbn,w office which operates the UST <br /> TYPE OF BUSINESS O O GAS STATION Q 2 DISTRIBUTOR I� RESERVATION 10 OF TANKS AT SITE E.P.A. I.D.i(A1dlAvep <br /> 0 3 FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST), PHONE a WITH AREA CGDE DAYS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> .S•fi/�/ ap <br /> NIGHTS: NAME(LAST,FIRST) PHONE fWITH 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 /> MAIL �STREET,JRESS .16oa bYxOnr INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> C/C/--JJ��61—y =1 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCV O FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Tor blWtYs INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> =CORPORATION D PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> CIN NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓Ice b k&jb L�j I SELF-INSURED =2 GUARANTEE Q 3 INSURANCE D I SURETY BOND <br /> =S LETEROFCREOT =a EXEMPTION E:3 W CTIER <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. 11.0 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNERS TITLE DATE MONTHADAYNEAR <br /> LOCAL AGENCY USE ONLY 35 <br /> COUNTY� # JURISDICTION i FACILITY i <br /> Imi 1401 ME <br /> "T <br /> LOCATION CODE -OPTIONAL CENSUS TRACTi- TIOAWL SUPVISOR-DIS7AK:T CODE •OP770NA1. <br /> A D <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 1S A CHANGE OF SITE(FORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FORDXII AAO <br />