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STATE OF CALIFORNIA �• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A p <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARKONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O a TEMPORARY 31TE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAE FACILrFY NAME <br /> NAME OF OPERATOR <br /> , 1 <br /> ADDRESS <br /> NEAREST CROSS ETRE PARCEL r( AU <br /> CITY NAM <br /> STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> CA <br /> TOINDICATE O CORPORATION (] INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY '�AUMV#GENCY' STATE#GENCY' FEOEILLL#(3ENCY' <br /> •N owner of UST is a public en e. DISTRICTS <br /> p agency,mnplete the followin name of Su rvicor of tlwisbn,section,or office which operates the UST r_ <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN r OF TANKS AT SITE E.P.A. 1.D.i(cpNmeQ <br /> Q 3 FARM = 4 PROCESSOR Ej> THER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE WITH ARA CODE DAYS:-NAME FIRST) PHONE WITH AREA CODE <br /> NIGHn: NAME(LAST,FIR PHONE# <br /> W TH REA NIGHTS: NAME(LAST,FIRST) PHONE WITHARCODE <br /> �7 - 76 <br /> " - <br /> EA; <br /> 3 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS df ` ✓hoobl a INDIVmIIAL �, L/3pCAL-AGENCY = STATE.AGENCY <br /> CORPORATION PARTNERSHIP LSYCOUNfVAGENCY Q FFDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE r WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER P CARE OF ADDRESS INFORMATION <br /> MAILING OR STREE ADDRESS l• ✓bo[ 0 INDIVIDUAL =�/LpCAl-AGENCY STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP Ua t`bVNTY#GENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Is WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4—F4--] L I l J I U <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓Nos bllglew Owr1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> =5 LETTEROFCREOIT =B EXEMPTION Q 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. it.52-'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 MCPTHIDAYNEAq <br /> H7 6P <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION At FACILITY <br /> m � a <br /> LOCATION CODE -OPTIONAL CENSUS TRACTi•CPTpNAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> /N 6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE EINFohmATibN ONLY. <br /> FORMA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> (393) <br /> FORODINAT <br /> Aws• <br />