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wss �� <br /> STATE OF CALIFORNIA �w is <br /> STATE WATER RESOURCES CONTROL BOARD ..,� a: <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'w� �+'' <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PER0AKVqY CLOSED SITE <br /> ONE REM r7 2 INTERIM PERMIT 4 AMENDED P 8 TEMPORARY SITE CL SURE s <br /> I. FACILITY/SITE IN <br /> FORIIIINTION 8 (MUST BECOMPLETED) <br /> DBA OR FACILITY / NAME OF OPEl R <br /> ADORES �. - Al NEARESTC STREET PIACELa(OPrIONAU <br /> CITY N E ZIPCQDE- <br /> 11 PHONE s WITH AREA CODE <br /> CA <br /> T.1 ASIA l�CORPORATION �ININVIUAL P IP LOCAL-AGENCY El COUNTY-AOENCY' (]STATEAGEACY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'Hamer of UST Iwobc agency,correlate the following: opervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS N Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(ap#awl) <br /> RESERVATION <br /> = 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST IL <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGil NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbioddo E::] INDIVIDUAL LOCAUAGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTYAGENCY 0 FEDEML-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlkaN D INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNIYAGENCY 0 FEDEML#GENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questlons arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓�bYWCW Q I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE A SURETY BOND <br /> O 5 LETTEROFCREDR 0 S EXEMPTION %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: I. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLE ,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTEDB SIGNED) OWNER'S TRLE DATE MONTHNAVFIEAR <br /> LOCAL AGENCY USE ONLY U/ <br /> COUNTY# JURISDICTION# FACIL N , <br /> LOCATIO C E -OP NAL CENSUS rr SUPVISOR-DISTRICT CODE--OP <br /> THIS F M 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) FOR003M-R7 <br />