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I <br /> w � � teoua e <br /> j STATE OFCALIFORMA ^+ o <br /> STATE WATER RESOURCES CONTROL BOARD w�� ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> V COMPLETETHIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLQSEDI <br /> ONE REM [:] IT 4AME 2 INTERIM PERMFQ,Pf RM`�V 6 TEMPORARY SITE Ig I <br /> I. FACILITY/SIT RMATION 6 ADDRESS-(MUST BE 1a� <br /> DBAORFACILITY ME / NAMEOFOPERATOR -QA v\` \ 1 <br /> 0 <br /> ADDRESS / NEAREST CROSS STREr PARCEL#)0 NAL) <br /> CITY NAME STATTEA ZIP CODE �� SITE P ONE#WITH A COD <br /> Vs L/ <br /> ✓ BOX RPORATION 0 IND (DUAL = PARTNERSHIP LOCAL-AGENCY D COUNTYAGENCY I�3TATE-AGENCY FEDERA NCV <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION RESERVATION I E.P.k I.D.#(op#onaO <br /> ❑ 3 FARM ❑ A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTA PERSON (SECONDARY)•optional <br /> DAYS: NA E(LAST,FIRST) PHONE#WITH AREA C DE DAYS: NAME(LAS ,FIRST) <br /> A GI e Lk, W / <br /> NIGHTS: NAME(LAST FIRST) PHONE#WITH AR DE AME(LAST,FI T) PHONE A WITH AREA COTIF <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / _ - ^ CARE OF ADDRESS) ORMATION <br /> MAILING OR STREET AADDDDRREEESSSS'' � N `� bmblrlficahi0 INDIVIDUAL 0 LOCAL-AGENCY Q STATEAGENCY <br /> O <br /> CORPORpf0N O PARTNERSHIP 0 COUNrY AGENCY 0 FEDERALAGENCV <br /> CITY NAME P QtJE#.WITH AREA CODE <br /> III. T WNER INFOR ATION-(MUST BEC PLETED) <br /> NAM FOWNER / i� / CARE OF ADDRESS INFORMATION <br /> M ILING OR STREET ADDRESS ✓ EoabiMkata INDIVIDUAL O LOCAL-AGENCY (] STATEAGEN <br /> 7 ✓ <br /> 0 dt"I Sr =CORPORATION PARTNERSHIP O COUMYAGENCY E=I FEDERAL-AGE Y <br /> CITY ME STATE ZIP CODE PHONE#WITH AREA <br /> IV. BOARD bF4QUALIZATION UST STORAGE FEE ACC UNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 <br /> 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSI COMPLETED —IDENTIFY SED <br /> ✓ Loa binCkale 7 1 SELNNSURED O 2 GUARANTEE [-13 INSURANCE A SUREN BOND <br /> J 5 LETTEROFCREDIT E__1 6 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: I.� I.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY(YEAR <br /> d- -9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURI ICTION# FACILITY# <br /> LOCATION CODE OPTIONAL <br /> - -E — _---- - — <br /> 3AL ENSUS TRACT# AL ISUPVISOR-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 /> FORM A 0291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> `�7y FORM33A R6 <br />