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STATEOFCAUFORMA .4 `" t} <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A *^ter <br /> COMPLETE THIS FORM FOR EACH FAOfIJTY1srm <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL 8ffr - <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE ` <br /> ------------------------------------ <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> ----------------- <br /> DBA O 1LITY N E <br /> -Z <br /> NAME OF OPERATOR <br /> :ADD SS <br /> NEARES R STREET <br /> PARCEL N(OPTIONAL) <br /> ' M <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ BOX CA <br /> TOINDICATE CORPO ATION INDIVIDUAL � PARTNERSHIP Q LOCAL-AGENCY COUflTY-AGENCY' <br /> If owner d UST Is a ubllo agency. g. DxSTRICTS' I� STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> P ® cy,complete the followln name of Supervisor of d v�krn,seoldon,or officewhich operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.*(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) PHONE#WITN AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> ZMALINGOReETDDRESS ✓ boxblRdicate <br /> 0 INDIVIDUAL = LOCAL•AGENCY E—)STATE-AGENCY <br /> CITY NAM CORPORATION [] PARTNERSHIP l�COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA GOpE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING DR STREET ADDRESS <br /> ✓ box m indicate 0 INDIVIDUAL LOCAL-AGENCY <br /> �CORPORATION �STATE-AGENCY <br /> CITY NAME = PARTNERSHIP © COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> 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 F4-T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate E-1 1 SELF-INSURED 2 GUARANTEE [] 3 INSURANCE <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION SURETY BONA <br /> I� 99 OTHER <br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner Unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPUTED UNDER P€MALTY OF PERJURY,AND TO TPE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED} OWNER'S TITLE <br /> DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 9 <br /> LOCATION CODE •OPTlOAfAI CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77IDlVAL _ k <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 /> FORMA(3+93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> _ FOR0033A-R7 <br />