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STATEOFCAUFORWA • .�� `: <br /> STATE WATER RESOURCES CONTROL BOARD s mom, :� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ft •,. o• <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �,�„o,,,,,.' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY <br /> ONE FrEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITVNAMEAUT^ ) � �Pf(,e� NAME OF OPERATOR <br /> NQ ADORES 4�+�LGi1�C `✓1T NEAR�STCRO S REET U a P/ACELA(OPfgNAq <br /> CITY# E STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> L n CA C7Jo20 to / �� /D/D <br /> ✓ Box <br /> TOINDICATE ,CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE.AGENCY' 0 FEDERAL AGENCY' <br /> 'x vNner of UST is a public DISTRICTS' <br /> D agency,complete the I011owing:name of Supervbor of dNkbn,eectbn,W oNics which operates the UST <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.a(oplknary <br /> 3 FARM = 4 PROCESSOR M 5 OTHER RESERVATION .ij <br /> OR TRUST LANDS J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#=COOC AREA- e /4?N TS: NAME( ,FIRST) PHONE N WITH AREA CODE NIGHT S: NAME(LAST,FIRST) PHONE N <br /> 7 htT 'f f/D/US 806 - 3,9- 77� <br /> II N- B <br /> NAME! ZCEOFADDRIESSINFORMA N <br /> U Vl (0 VLMAIL R S MkaleD INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 12 RATION 0 PARTNERSHIP COUNrY-AGENCY O FEDERAL-AGENCY <br /> CITY © ZIP DE PHONE#WITH AREA CODE <br /> t'[ V` <br /> OWNERIll. TANK INFORMATION-(MUST BE COMPLETED) <br /> NA OFOWNER CARE OF ADDRESS INFORMATION <br /> i'ee_/- /hria)L-�07) %f�2 <br /> MAILI ORSTREET ADDRESS - ✓boa tolndkaW O INDIVIDUAL O LOCAL LSC/ S-, OSTATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NA_MC STA ZIP ODE PHONE#WITH AREA CODE <br /> JcfUI�J 6ao6Caxr)gy-a-/oio <br /> IV.BOARD OF EQUALIZATION UST STO AG EE ACCOUNT NUMBER-Call(9 16)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 2 y g a 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bot b Indicate 0 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> 0 5 LETTEROFCREIXT O 6 EXEMPTION O I SURETYBOND <br /> 0 7B 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: <br /> I.[::] II.[::] <br /> THIS FORM HA N MP TED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OW 'S N P D 6 ED) OWNER'S TITLE DATE MONT AY%EAR <br /> 3 <br /> LOCAL AGENCY USE ONLY ?5Q5 <br /> COUNTY# JURISDICTION# FACILITY i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTA)W SUPVISOR-DISTRICT CODE •TW77OWAL IAJ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. ll <br /> FORM A(3'B3) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • � �'/�� /� FOR0033A.117 <br />