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• eC60Ue [} . <br /> STATEOFCAUPDRNIA :[ o ^o <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °��[oe"'' <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 17o <br /> I. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 3o <br /> TOIN Box f�CORPORATION Q INDIVIDUAL q POTNERSHIP 0 LOCAL-AGENCY DISTRICTS' O COUNFY-AGENCY' STATE-AGENCY' OFEDERAL-AGENCY' <br /> ' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of dNkbn.eectbn,or.Nice which operates the UST <br /> INDIAN ITYPE OF BUSINESS GAS STATION Q 2 DISTRIBUTOR RESEIRVATION # TANKS SITE E.P.A. I.D.#(opriarW) <br /> 3 FARM D A PROCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHT NAME(LAST.FIRSq <br /> PHONE#WITH AREA 655E NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> , 1 _ S ..� i �. •�r,<p <br /> II. PROPERTY OWNER INF RMA ION- MUST BE COMPLETED <br /> NAME y„ �r '� T CARE OF ADDRESS INFORMATION <br /> 4-lye _— <br /> MAILING ORSTREET ADDRESS ✓ box toin6kes D INDIVIDUAL LOCAL-AGENCY =1 STATE-AGENCY <br /> S CORPORATION ARTNMSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE CODE <br /> O V:2142III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER ,. _,� q rl /�Y — CARE OF ADDRESS INFORMATION <br /> T <br /> MAILING OR STREET ADDRESS ✓ box wind1°ats D INDIVIDUAL LOCAL AGENCY Q STATE-AGENCY <br /> �' �, I CORPORATION PARTNERSHIP COUIRY#GENCY FEDERALAGENCY <br /> CITY NA E STATE ZIP CODE PHONE If 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- -IF _� 1_ 1:1_] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkale -- t SELF-INSURED =2 GUARANTEE =3 INSURANCE O A SURETY BOND <br /> 5 LETTEROFCREDIT 0 6 EXEMPTION E-1 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: I. IL D 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) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTx)ANL <br /> 7 <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 /> FORM APO) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> . FOR0333AA7 <br />