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4A� <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT <br /> 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br /> ONE REM Q 2 INTERIM PERMIT E::] 6 AMENDED PERMIT G TEMPORARY SITE CLOSURE <br /> I. FACILrrY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> APA 04 FACILITY N.ME NAME OF OPERATOR <br /> r <br /> r <br /> ADDRESS NEARESTCROSS STREET PARLELI(OPrK 4 <br /> A 1.7 <br /> so <br /> CITY NAME STATE ZIP E �D J SITE PHONE!WITH AREA CODE <br /> V BOX <br /> TOINDICCACA'TE CORPORATION O INDIVIDUAL PARTNERSHIP f� LOCAL-AGENCY I�COUNTYAGENCY✓* O STATE-AGENCY' O FEDEPAL-AGENCY' <br /> N inner ot UST is a public agency,cbrrple at the following:narne of Supervkor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS [�] 1 GAS STATX)N Q 2 DISTRIBUTOR -/ IF INDIAN X OF TANKS AT SITE E.P.A. I.D. i0primal) <br /> O <br /> 3 FARM Q 4 PROCESSOR Q RESERVATION <br /> S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONEl WITH EA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> ao9 — / <br /> NIGHTS: NAME ,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a-WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME j CARE OFA DRESS INFORMATION <br /> I�ui <br /> MAPMAILINGO ST/{iEETADDR SS yy ✓botbindkaU � INDIVIDUAL O LOCAL-AGENCY (] STATE AGENCY <br /> j iw,)L► l�CORPORATION O PARTNERSHIP COUNTY AGENCY [7j FEDEMIAGENCY <br /> CITY NAM STATE ZIP DE PH NEl WIT AREA CO <br /> C CoQ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER y� CARE OF ADDRESS INFORMATION <br /> ((N/ <br /> MAILING OR STREET ADDRESS ✓ b bebkap 0 INDIVIDUAL D LOCAL-AGENCYIS STATE-AGENCY <br /> CORPORATION M PARTNERSHIP COUNTY AGENCY D FEDERALAGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓EwbbWCW 0 I SELF-INSURED [�j 2 GUARANTEE [-13 INSURANCE 0 A SURETY BOND <br /> O 5 LETTER OF CREDIT O S 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.E—] II. III.O <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 a SIGNED) OWNER'S TITLE DATE MONTHA)AYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a ACILTTY <br /> LOCATION CODE -OPTfONAL CENSUS TM"!-OP NAL 9UPVISOR-DISTRICTI _ - I- <br /> C7lH C-� F/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS S A CHANGE OF SITE i"mmiblil 6NLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> fOR000M8T <br /> /o - 3 - 5'4- 1 C- 9 -V(10 ,�3 <br />