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�, w ✓ 'isou• � <br /> STATEOFCAUFORNIA .` o <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD y v� :• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS'(MUST BE COMPLETED) <br /> DBA Qg;ACW TY NAME NAME OF OPERATOR <br /> 7_— ZLt. <br /> ADDRESS NEAREST ROSS STREET PARCEL 0(OPTIONAL) <br /> Zia SS er <br /> C NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> CA <br /> r 10 NDICATE 106PORATION O INDIVIDUAL ED PARTNERSHIP O LOCAL-AGENCY Q COMTY-AGENCY• STATE-AGENCY' O FEDERu#GENCY' <br /> DISTRICTS' <br /> 9 owner d UST is a public agency,complete the following:name of Supervisor of division.section,or office which operate,the UST <br /> TYPE OF BUSINESS n f qq5 STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.4(cptAnap <br /> L12r/s 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 COD DAYS: NAME MST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS:NAME(LAST.FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME`—. CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 1 .1 box b Imill 1l INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Z-19S 'SO O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME IF STATES ZIP CODEO S PHONE A WITH AREA CODE <br /> —yr7 <br /> III. TANK 0 NER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S <br /> MAILING OR STREET ADDRESS ✓ bosblrlAkaM INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP O COUNTYAMNCY 0 FEDERALAGENCY <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 questions arise. <br /> TY(TK) HQ 4 4- -LL-A -I -I I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> to,tulntlkale O f SELF-INSURED 2 GUARANTEE L--1 3 INSURANCE [--]4 SUREIYBOND <br /> 5 LETrER OF CREOT O S EXEMPTION O 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.= if.E< 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(PH INTED&SIGNED) OWNER'STITLE DATE MONTHMAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CSODU�NTTYY��A JURISDICTION 0 FACILITTY S <br /> SEZO <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OIPTIONAL SUPVtSOR-DISTRICT CODE -OPTIONAL <br /> L <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(3931 FONOMU-117 <br />