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STATEOFCAUFORIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °.�,.a-�'• ' <br /> MARK ONLY 1 NEW PERMIT RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT LJ AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> � NAME OF OPERATOR <br /> 1' a <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFrONAU <br /> CITY NAME STAT ZICA Q�Z 9ITEHOEPPNE#WI AREA <br /> V ! �f — 7 <br /> V Box <br /> TO INDICATE E-1 CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCALAGENCY Q COUNTYAGEICV' O STATE-AGENCY' ED FNIERALAGENCY' <br /> N owner d UST Is a public agency,complete the foA name d S <br /> DISTRICTS' <br /> owing: Supervisor oNbbn.aeclbn,or offics ISRICTS'hbh operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN s OF TANKS AT SITE E.P.A I.D.#pp6onall <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER RESERVATION <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST).. -- JJ P,HONE{WITH AR CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> YGclre �YvlF LGA) 3 ^ �! <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE N04TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> YGB 1 <br /> MAILINGOfl STREET ADDRESS ✓ bm b Insists 0INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP (]COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 9�FZ�D <br /> 111, TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF�J=q_ 1 r TS l CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS J ✓ EubirMiccb 0 INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> [� / / '.'►tl OCORPORATION O PARTNERSHIP O COUNIYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE It WITH AREA CODE <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916))33222-966699 if questions arise. <br /> TY(TK) Hp4 4- - o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hm bbAofe 0 1 SELF-INSURED O 2 GUARANTEE ED 3 INSURANCE O#SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 0 99 OTHER <br /> Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.0 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAIVE(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNNTT-Y-��a JURISDICTION# FA�CCILITYY##�/�� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 T GULATIONS <br /> FORM A(393) FC1o93AA7 <br /> �Raa�l <br />