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STATE OF CALIFORNIA `^^0� of <br /> STATE WATER RESOURCES CONTROL BOARD p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE - t In o <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA;;AC ITY NAME NAME OF OPERATOR ADDRESS p NEAREST CROSS STREET PARCEL t(OPTIONAL) <br /> z 7 <br /> CITY NAME STATE ZIP CODE E PHONE N WITH AREA CODE <br /> ��Nv' CA c <br /> ✓BOX I�CORPORATION Q INDNIDIAL ERSHIP lj LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY• <br /> TO INDICATE DISTRICTS <br /> 'tlorANrdUST is apdffeagmq,mmplda Mo MlMwngi ofsupeNkor tiD.ion,leionwffawhichopeWft Na UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR I ❑ ✓IF INDIAN #OF TANKS AT SITE I E.P.A. 1.D.#(optional) <br /> RESERVATION w <br /> 0 3 FARM Q # PROCESSOR Q S OTHER OR RESERVANDS L <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAMECARE OF ADDRESS INFORMATION <br /> 3F4nl -rb o -rl <br /> MAILING OR STREET A RESS �-I ✓ bu:o F'm" = INDIVIDUAL =LOCAL-AGENCY = STATE-AGENCY <br /> Z9LPrI t - AE =CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ONE#WITH AgEA CODE <br /> 9SZ/Z ZSR 9a/ - o?f'� <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAMEOF NER1� ���/� CARE OF ADDRESS INFORMATION <br /> MAILING <br /> OORSTRE ODRESS /^� ✓ lax 1p ndcofe Q INDIVIDUAL Q LOCAL-AGENCY E3 STATE AGENCY <br /> 1101/ ^ O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE 4 PHON&N WITH AREA CODE <br /> )W♦ Q#) —© <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 METHOD(S) USED <br /> ✓botro b�pb Q I SELF-INSURED =2 GUARANTEE 1=3 INSURANCE (]<SURETY BOND Q 5 LETTEROFCREOR O 6 EXEMPTION 0 7 STATE FUND <br /> = 8STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE FUND&CERTIFICATE OF DEPOSIT O fB LOCAL GOVT.MECHANISM O99 OTHEi1 <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.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Orr— <br /> m 12 o9 ft' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 FOP"WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(695) lbW *404 <br />