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r�6�Vp C°c <br /> STATE OF CAUFORMIA <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> .2 n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&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 /> CAL� <br /> ✓ BOX ,�,/ <br /> TOINDICATE CORPORATIONQ INDIVIDUAL 12-PARTNERSHIP © LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAWIGENCY` <br /> DETRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of d"lon,section,or office which operates the UST <br /> TYPE OF BUSINESS L 1 GAS STATION = 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E,P-A. I.D.#(ap conal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 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 /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE i- NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> f.1 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME J , r)) ()7 CARE OF ADDRESS INFORMATION <br /> f /h ' D07- <br /> MAILING OR rSTREET ADDRESS/ J Dox to iridlcars 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION [PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIM NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> vd� rX c- L 2 6 7 f42 2 O3 7,) <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER /-?;0'LI "'1-9-0, "P S n Yen <br /> / CARE OF ADDRESS INFORMATION <br /> l7/ e z <br /> MAILING OR STREET ADDRESS Ci r V box b indieaia INDIVIDUAL <br /> / 0P NCY <br /> J I�(i�( L (J d �� CORPORATION [� PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CIM NAME STATE ZIP COOE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 74F47- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)--IDENTIFY THE METHOD(S) USED <br /> ✓ IxoxIDirdicate 0 1 SELF-INSURED [:]2GUARANTEE l= 3INSURANCE 4 SURETY SONO <br /> 0 5 LETTEROFCREDIT 1=6 EXEMPTION [--j 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: L 0 it.Ej III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY)CNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NA (PRI TED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> a e "),p L [ /.u'�F �- Jf L'D� CCJ�IJ pP � f' / <br /> _ / o <br /> LOCAL AGENCY USE ONLY / <br /> COUNTY# JURISDICTION# FACILITY <br /> Lo <br /> LOCATION CODE •OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPT)ONAL <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 /> FORMA(3W) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG40UND STORAGE TANK REGULATIONS <br /> FORD033A.R7 <br />