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ass <br /> STATE OF CAUFORtaA <br /> STATE WATER RESOURCES CONTROL BOARD W"!BI a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A '0 .• °a <br /> COMPLETE THIS FORM FOR EACH FACILIFYISfTE °�11Oe�� <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION O T PERMANENT SED SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT LrJ1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DS FACILITY NAME NAMED ZIOR <br /> AD S NEARE TCROSS ST EET ' PARCEL AfOPTIONM) <br /> CITY E STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> CA <br /> TOINGCAXTE Q CORPORATION INDIVIDUAL Q PARTNFASNIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY• Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •X diner of UST Is a public agency,contrabass the lobowing:name of Supervisor of d"lon,section,or o111ce which Operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ,/ IF INDIAN i OF TANKS AT SIT�P. �(qxm <br /> RTION <br /> 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAP NAME(LAST,FIRST, PHONE i WI H REA CODE DAYS: NAME(LAST,FIRS PH NE i WITH AREA CODE <br /> _ / <br /> 4 64 <br /> N TS: NAME(LAST,FIR P E i H REA CODE NI HTS: NA (LAST,FIRS0 NEA WITH AREA CODE <br /> Q / <br /> y4> <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREET ADDRESS ✓ box bindbab Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUKTYAGENCY Q FEDERALAGENCY <br /> CITY NAM ST TE ZIP DE PHONE a WITH AREA CODE <br /> III. TANK 0 NER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF O NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STRttf ADDRESS ✓ boxbindbale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY IQ FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE It 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—W- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa b Indicate [=1 1 SELF INSURED Q 2 GUARANTEE 0 3 INSURANCE Q a SURETY BOND <br /> 0 5 LETTEROFCREDIT Q 6 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL EA III-0 <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 6 SIGNED) OWNER'STRLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY — <br /> COUNTY i JURISDICTION• FACILf1V f <br /> aq] 22im 23 Zm 10- <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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3N3) Follmm MO <br />