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."� STATE OF CALIFORNIA ,s w a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE U <br /> I. FACILITYISITE INFORMATION b ADDRESS•(MUST BE COMPLETED) /OA/0d <br /> DBAO ACILI AME NAMEPER(rT®R <br /> ADDRESS NEAREST CROSS STREET PARCEL e(OPrIONAL) <br /> Z <br /> CITYN ME STATE ZIP CODE 3 SITE PHONE)WITH AREA CODE <br /> TO IND RTE CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O C00(JUNTY-AGENCY' O STATE AGENCY' O FEDERAL AGENCY' <br /> DISTRICTS' <br /> R owner A UST Is a Public agency,complete the foNowing:name of Supomisor of dNbbn,seclbn,w ofiioe which openates the UST <br /> TYPE OF BUSINESS STATION 0 2 DISTRIBUTOR O RESERVATION <br /> IF INDIAN <br /> a3 FARJ OF TANKS AT SITE E.P.A. I.D.J(optional) <br /> M 4 PROCESSOR 0 5 OTHER OR TRUST LANDS r <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(I T,FIRS7n� PHONE$WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE J WITH AREA CODE <br /> c�a /G " — 7 - a3 J <br /> NIGHTS: NAME(LAST,FIRST) PHONE)WITHA EACODE NIGHTS: NAME(LAST,FIRST) PHONE J WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME/1 CARE OF ADDRESS INFORMATION <br /> MAILING/OlaRSTREET ADDRESS/ `� IxAbindests INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> -' CORPORATION D PARTNERSHIP O COUNTY-AGENCY FEDERAL AGENCY <br /> CITYANAME / STATE ZIP CODE PHONE J WITH AREA CODE <br /> C,4 2LZ-U <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bar biWicale E-1 INDIVIDUAL O LOCAL AGENCY O STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP O COUNTYAGENCY D FEDERAL AGENCY <br /> CITY NAME STATE 21P CODE PHONE Al WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4L4] <br /> V <br /> 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ws b IMbate 1 SELF-INSURED E]2 GUARANTEE l= 3 INSURANCE 0 A SURETY BOND <br /> 5 LETrEROFCREDT [__3 6 EXEMPTION E-:3 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. /III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED A SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILfTY s <br /> 0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT$ -OPTpNAL SUPVISOR-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 iwoiltmnok ONLY. rA <br /> FORM A(3A13) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOROM <br /> � lig tm(oo �� �� <br />