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STATE OF CALIFORNIA .! <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE +�•oa"`' <br /> MARK ONLY F__j t NEW PERMIT 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION x7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE YYYYY / <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NP-ME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME ST CA 21P DE PHONE WITHAREACCIDE <br /> deflIZOG8 7 <br /> TOINDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-A13ENCY' O FEDERALAMWy- <br /> DISTRICTS' <br /> X com d UST Is a public agency,corrplde the following:narre of Supenleor of&Isbn.section,W office which operates the UST <br /> TYPE OF BUSINESSI GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A 1.D.#(cpemap <br /> RESERVATION <br /> 3 FARM Q a PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optioned <br /> DAVf:NAME(LAST,FIRST) a PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> QJC <br /> NWME NAME(LAST,FIRS PHONE#WrM AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING OR STflEET ADD ES/g /�XA/l'/F•,•I ^. A�/� (/�/� ✓ bubintlkale T�YINDIVIDUAL I� LOCALAGENCY STATE-AGENCY <br /> / u/{'VL�,Fi iL \ s =CORPORARON f:1 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMEST/1TE ZIP CODE PHONE#WITH AREA CODE <br /> G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boy baNkaM D INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION [] PARTNERSHIP ED COUNTYAGENCY D FEDERAL AGENCY <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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Goy bMksY O I SELF INSURED O 2 GUARANTEE 3 INSURANCE O A SURETY BOND <br /> D 5 LETTEROFCREDIT a 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: 1.0 ll.EJ IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNERS TITLE DATE MONTKDAYNEAR <br /> LOCAL AGENCY USE ONLY D <br /> COUNTY# JURISDICTION d <br /> � zro7 <br /> LOCATKIN CODE -OPTIONAL CENSUS TRACT-OPTIONAL SUPVISOR-DISTR -CODE -OP 'n I <br /> OW o <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) FORD M-R7 <br />