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leeW! ! <br /> STATE OFCAUFORNIA �! <br /> STATE WATER RESOURCES CONTROL BOARD :��, ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE � �.�„o„„,!' <br /> MARK ONLY ED O NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME C NAME OF OPERATOR <br /> 'nzwe <br /> ADDRESS NEAREST CROSS STREET PpACELI(OPrgNAL) <br /> Z �i✓T'G <br /> CITY NAME STATE ZI CODE SITE PHONE#WITH AREA CODE <br /> 7� <br /> ✓ eox CA <br /> TOINDICATE O CORPORATION O INDIVIDUAL E--1 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' =1 STATE-AGENCY' C:j FEDERAL-AGENCY' <br /> I owner d UST la a public agency,oonplete the followin :name d Su DISTRICTS' <br /> roffic <br /> g Supervisor 6Nrebn,section. which operates the UST <br /> TYPE OF BUSINESS f GAS STATION Q 2 DISTRIBUTOR ✓ IF IN-DANT-­OF AT SITE E.P.A. 'I.D. (gNianal) <br /> 3 FARM O 4 PROCESSOR QATION <br /> I OTHER OR TRUSTVLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONES a WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> J <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> I r7T <br /> MAILING OR STREET ADDRESS ✓Co[bin6kAl 0 INDIVOUAL (] LOCAbAGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUWYAGENCY =1 FECERALAGENCY <br /> C E STATE ZIP CODE PHONE I WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) C/3 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bszblAkLe INDIVIDUAL 0 LOCAL-AGENCY STATE.AGENCY <br /> fT CORPORATION PARTNERSHIP = COUNAGENCY Q FEDERAL-AGENCY <br /> CITY TYSTATE ZIP CODE PHONE#WITH AREA CODE <br /> 6D� _ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bw to Indicate (]1 SELF-INSURED =2 GUARANTEE = 3 INSURANCE O SURE7Y BOND <br /> O 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.0 IL l 7 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Is JURISDICTION a FACILITY# <br /> ED is � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SIU711-DISTRICT CODE -OPTIONAL <br /> 3 • 7 /7l <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 0 A CHANGE OF SITE INFORMATION ONLY. k <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY ILLPLEMF-NTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) - w <br /> � l�/# <br /> `/ ~ Y ` <br />