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14W a STATEOFCAUFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 d AMENDED PERMIT E] a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FACILITY AME NAME OPERATO p <br /> O V_UJA/QALY_/ <br /> 2XL�W4LIJSO A4 <br /> ADDRESS NEARESTCRO iSTREET P LN(OPFIONAU <br /> 6 Ll S . <br /> CITY NAM STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> CA <br /> ✓BOx D 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAUAGENCY' <br /> TOINdCATE CORPORATION INDIVIDUAL DISTRICTS' <br /> If owner of UST Is a public agency.oanplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORq V IF INDIOIAN N #OF TANKS AT SITE E.P.A. I.D.0 tnpfionap <br /> 3 FARM Q # PROCESSOR 5 OTHER OR TRUST LANDS V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRS PHONE#WITH AREA CODE DA S: NAME( ST,FIRST) PHONE#WITH AREA <br /> �4 LbZ <br /> NIGHTS: NAME(LAST,FIR HONE#WITH REA CODE NIGHTS: NAME(L AST,FIRST) PHONE ArWITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSo Ind INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 2 C� ✓ CORPOMTION Q PARTNERSHIP E71 COUNTYAGENCY FEDERAL AGENCY <br /> ITV E STATE ZIP ODE PHONE If WITH AREA CODE <br /> G9- r3 Q3 / - X03 zG <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓LOC It indica- INDIVIDUAL LOCAL AGENCY 0STATE AGENCY <br /> 11 CORPORATION O PARTNERSHIP 0 COUNTY AGENCY FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#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. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓oc bindbale I�1 SELF-INSURED 2 GUARANTEE E-1 3 INSURANCE O A SURETY BOND <br /> 5 LETTEROFCREDIT O 6 EXEMPTION = 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II. 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 B SIGNED) OWNER'STITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY JA <br /> COUNTY# JURISDICTION# FACILITY <br /> alil ® I2 3 / 7I tI <br /> LOCATION CODE -OPTIONAL CENSUSTMCT#-OPTTONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> `L.J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE moiimiON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3.93) FORD(l <br />