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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBApgFACILRY NAME N OF ERATOR <br /> nai <br /> ADDRRE <br /> m NE ES C SSS E P -EI a(OPrpNAU <br /> CI / <br /> STA ZIP SITE PHONE S WITH AREA CODE <br /> CA <br /> IOX <br /> T NOCATE I1 CORPORATION INDIVIDUAL E:I PARTNERSHIP O LOCAL-AGENCY ED COUNTY-AGENCY• a STATE-AGENCY' O FEDERALAGENCY' <br /> •N cater d UST is a public DISTRICTS' <br /> p aeenq,csmplela iM topowlnp:nazre b Supervisor of Eiviion,section.W office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANK qT SITE E.P.A. I.D.A(cpnwwJ <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q a OTHER Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIfl3T) PHONEi WITH AREA CO DE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bmbin*AW D INDIVIDUAL 0 LOCAL-AGENCY 0 STATEAGENCY <br /> V V •' — O CORPORATION [:j PARTNERSHIP ED COUNTY-AGENCY 0 FEDEML-AGENCY <br /> STAT <br /> CITY NAME E ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓buthdkes INDIVIDUAL E-1 LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION E2 PARTNERSHIP COURTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHO NE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIALRESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓bos biMbaN 0 ELF-INSURED I� 2 GUARANTEE Q URANCE A SURETY BOND <br /> S LETTER)F CREDIT E--1 6 EXEMPTION 6e 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 /> CHECKONE BOX INDICATING WHICHABOVE ADDRESSSHOULDBE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST CF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 6 JURISDICTION JF FACILITY x <br /> � P� C �� 9qI <br /> LOCATION CODE -OPTIOL L CENSUST iT. SUPVISOR-DISTRI'g /M 2 <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 /> FORMA(393) FORIXDYIAI <br />