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W^ <br /> STATE OF CALIFORNIA �� ' <br /> STATE WATER RESOURCES CONTROL BOARD W o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A > <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE `'��•�^"'� <br /> MARK ONLY 3 NEW PERMIT Q 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT E::] 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST Cfl053 STREET PARCEL#(OPfK)NAU <br /> 1470 c. IColAxe. <br /> CITY NAME O� STATE <br /> Z1SITE PHONE 0 WITH AREA CODE <br /> ATCA <br /> TO V, Box <br /> INDITE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTYAGENOY• O STATE-AGENCY• O FEDERALAGENCY• <br /> DISTRICTS' <br /> •x owner of UST is a Public agency.oonViete the following:name of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS X, GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(bPeonal) <br /> $FARM 0 4 PROCESSOR = 6 OTHER OR RESERVATION TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME MST,FIRS n 1 PHONE 8 WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> ErGG NI 7J Y <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> K-EVI&I E/DG <br /> MAILING OR STREET ADDRESS ✓ bol 10 Mica 0 INDIVIDUAL LOCAL AGENCY Q STATE-AGENCY <br /> /00 e, Zt>,dj A�fE. OCORPORATION PARTNERSHIP (] COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW R CARE OF ADDRESS INFORMATION <br /> Aeycid <br /> MAILING OR STREET ADDRESS ✓ bm tliMN91s INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> /QD r �f�- CORPORATION O PARTNERSHIP O COUWYAGENCY FEDERAL-AGENCY <br /> CITY NAME 9TA ZIP CODE PHONE#WITH AREA CODE <br /> Gv� �i z v <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-]-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Im bYMieale D I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> E-1 5 LETTER OF CREDIT 6 EXEMPTION 0 99 OTHER <br /> VI. 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: LD II.Q III.El <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&SIGNE D) OWNER'S TITLE DATE MONTH"Y/YEAR <br /> LOCAL AGENCY USE ONLY 1 <br /> COUNTY# JURISDICTION# FACILITY It <br /> 1,6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUWISOR-DISTRICT CODE -OPTIONAL -� <br /> OZ 23. 30 t I <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 TANK REGULATIONS <br /> FORM A(393) FOROm3M17 <br /> \/ 't <br />