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\J ft"4W^ C C <br /> STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CL29DSITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 B TEMPORARY SITE CLOSURE 1 <br /> I. FACILTTYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORILITY NAME NAME OF OPERATOR <br /> ADDRESS <br /> e NEAREST CROSS STREET PARCEL a(OPfONAy <br /> CITY Ni�� STATE ZIP CODfn91 PHON aWl AREA CODE <br /> CA <br /> Bx <br /> TO INDICATE CORPORATION O INDNDUAL 0 PARTNERSHIP O DBTNCT�Y 0 COUNTYAGENCY' O STATE-AGFNCY' D FEDERALAOENCY' <br /> N owner d UST Is a public agency.ccrrpWe the folowing:name of Supervisor of division, ;eclion,cr duce which oppates the UST <br /> TYPE OF BUSINESS O f GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIAN <br /> A OF TANKS AT SITE E.P.A. I.D.0(q donaQ <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NA (IA.ST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(LAST, HONE a WITH 1/GO NIGHTS: NAME((LAST,FIRST) PHONE a WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMA N I <br /> MAILING OR STREET DRESS ✓ b INDIVIDUAL LOCAL-AGENCY STATE- Y <br /> �f f�CORPORATION O PARTNERSHIP D Cd1NTYAGENCY FDOERAL-AGENCY <br /> CITY c �' ZIP CODE O� PHONE/� H ARE;CODE �� <br /> IIL TANK OWNER INFORMA ON-(MUST BE COMPLETED) /`7 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bw to Ndlesw INDIVIDUAL (] LOCALAGENCY STATE-AGENCY <br /> O CORPORATION PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV D OF EQUALIZATION UST STORAGE ft&kCCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-F4-1 <br /> V. P\6ipOtEtlkFt?STTIIQANC (MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓6M bYdka4 O f SELF-INSURED =2 GUARANTEE O 3 INSURANCE f�4 SURETY BOND <br /> O 5 LETTEROFCREDIT (]5 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be send 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: L[] ILN <br /> . III. <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&SIGNED) OWNE R'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY a <br /> COUNTY a JURISDICTION• FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS THACTa•OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> 8 a o coo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPUCATION- FORM B,UNLESS THIS IS A CHANGE OF SITE 1WORMA11ON ONLY. <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS wrmm3Aa7 <br /> Do aof i SsuA- � � �(�1� I..IID- 95 � ' <br />