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STATE OF CALIFORNIA <br /> Fj <br /> �°�,f 91M <br /> PT E WATER <br /> RESOURCES CONTROL BOARD <br /> ORAGE TANK PERMIT APPLICATION - FORM A , a' <br /> J0 C T 2 9 1993 COMPLETE THIS FORM FOR EACH FACILRY'SITE °..,,ea+•" <br /> MARK ONLYntr /��[[pp EWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM � 2 Pf!NAhTR 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA ILITV NAME NAME OF OPERATOR <br /> ADDRESS \ r N ES CROSSS EET _ PAACELe(OPTONAU <br /> t <br /> CITY NAME * ST TE Zip SITE PHONE A�WITH AREA CODE <br /> �J\ a 195 <br /> 5 <br /> v Box <br /> TO INDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCALAGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL AGENCY' <br /> If owner a UST Is a public agency,cenpble the tolbm <br /> wln9:nae of Supervbor of division.section DISTRICTS',or office which operalea the UST <br /> TYPE OF BUSINESS O l GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN IN OF TAN AT SITE E.P.A. I.O.a fow-all <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> MERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optiond <br /> DAYS: NAME(LAST, RST) PHONE a WITH AREA CODE DAYS: NAME RAST,FIRST PHONE If WITH AREA CODE <br /> NIGHTS:NAME(LAST,FI ST PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST PHONE a WITH AREA CODE <br /> if. PROPERTY OWNS INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabindrale O INDIVIDUAL O LOCAL-AGENCY M STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O CWNTYAGENCY [I] FEDERAL-AGENCY <br /> CITY NAME STATE 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 ✓boa b Irdeas INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP 0 COUNTYAGENCY (]FEDERAL-AGENCY <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 M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY.(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bbdan, 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT 6 EXEMPTION 0 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 /> C14ECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] II.[::] III. <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(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAWYFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION• FACILITY 0 <br /> LOCATION CODE -OPTIONAL CENSUS TRT* -O <br /> ACPTIOlitl, SUPVISOR-DISTRICT CODE -OP7pN4L <br /> THIS FORM MUST 9E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A CM OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY I MING THE UNDERGROUND STORAGE TANK REGULATIONII P01100Mat7 <br /> /lois #Y <br />