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srarsovCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FAgLITY131TE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> � r <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT E] a TEMPORARY SITE CLOSURE L, <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYNAME NAMEOFOPERATOR <br /> ADAIS. S NEARS CROS$9TREET _ PARCELS(OPTIONAL) <br /> CITY NAME STATE ZIP �-,./�-� SITE PHONE 0 WITH AREA CODE <br /> �e,Y��-C � CA e� <br /> TO <br /> BOX <br /> OATE COgPORATION Q INDIVIDUAL PARTNERSHIP � DISTRICTS' <br /> ED COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> It owner of UST is a public`agency,complete the following:panne of Supervisor of division,section.or attics which operates the UST <br /> TYPE OF BUSINESS ❑ T GAS STATK)N 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS ATSITE E.P.A. I.D.•(cplwTal) <br /> 3 FARM Q4 PROCESSOR 5 OTHER OR / IF IN <br /> DIAN TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE 0 W H AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IS <br /> NIGHTS: NAME(LAST. IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot blMRSN 0INDIVIDUAL O LOCAL AGENCY QSTATE-AGENCY <br /> ED CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEOERA4AGENCY <br /> CITU NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ <br /> box bindnate O INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION l� PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- -Q�] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box bindbate = 1 SELF-INSURED =2 GUARANTEE d INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O a EXEMPTION IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E] It. 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&SIGNED) OWNER'S TIT LE DATE MONTWDAYrVFAR <br /> LOCAL AGENCY USE ONLY G Z I,) 2 - <br /> C�O.�U�NTTYr�# JURISDICTION# F�A�C�I�L-I�T-Y## <br /> LOCATION CODE -OPTIONAL CENSUS T :OPTfQNAL SUPVISOR-DISTRICT OD <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS 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 AT&W) • 67—�q./ L z� <br />