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STATEOFCAUFORWA �� c'o <br /> STATE WATER RESOURCES CONTROL BOARD A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ';affi . <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE � `' .o."'�D <br /> MARK ONLY O f NEW PERMIT O 3 RENEWAL PERMIT Q S CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE C <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OFO ERATOR D <br /> r <br /> A NE S CRO TREET P I(OPTI NAW <br /> I STATE ZIP SITE PHONE a WITH AREA CODE <br /> S CAV Box <br /> O <br /> T NDICATE CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS <br /> T9 Y O COUNTYAGENCY' O STATE-AGENCY' = I MERIL#GENCY' <br /> If owner of UST M a public agency,complete the following:name ol Supams or of division.section,or office which operate,the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR0 RE✓/ IF INDIAN 11 OF TANKS AT SITE E.P.A. I.D.0 topido") <br /> TON <br /> O 3 FARM Q 4 PROCESSOR = S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRJSPn L. (EHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ZY& <br /> IX0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a TH AREA <br /> A CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> i <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEDO C OF ADDRESS INFO BION /a' <br /> a a Gi 0 <br /> M&Wbp OR^STRE ADDRESS n Z' buabindbala INDIVIDUAL O LOCAL- Y STATE AGENCY <br /> O� D W t✓ =CORPORATION PARTNERSHIP 0 COUNTYAGENCY 0 FEDERALAMMY <br /> C17Y NAME ^ B�TE� ZIP CODE PHONE a WITH AREA CODE <br /> 4a ce� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMOF OWNER RE OF ADDRESS INFORMATION <br /> r <br /> MAILINGOR T EETADDRESS .1 box bidicap, INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> E3 CORPORATION O PARTNERS., Q COUNTY-AGENCY FEMRALAGENCY <br /> CITY ST,Th. ZIP 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- - 3 al <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> yM bNiAcals 1 SELF-INSURED =2 GUARANTEE O 3 INSURANCE D 4 SURETY SOND <br /> 5 LETTEROFCREDIT ED S EXEMPTION 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: 1.0 II. 111.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTP"YIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION• FACILITY All,115 <br /> b <br /> LOCATON CODE -OPTIONAL CENSUS TRACT, -OPTIONAL SLIPVISOR-DISTRICT CODE - <br /> b?� O©O <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 /> FORM A(3im1 I•/v <br />