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0 <br />STATE OF CALIFORNIA �[ o r� <br />STATE WATER RESOURCES CONTROL BOARD + vim, a <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILRYISITE °��,[cer" <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE REM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE D-7-7 <br />I. FACILITY/SITE INFORMATION&ADDRESS - (MUST BE COMPLETED) ypcfl . aI <br />FORA OR FACILITY NP.ME <br />NAME OF OPERATOR <br />/ <br />OG//hl <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />oD o0� <br />tiowE,e SAG <br />✓ bot bin#kals � INDIVIDUAL <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE a WITH AREA CODE <br />/,0 0_7-- <br />CA <br />CITY NAME <br />s� lea(64— <br />Z 3 -9 <br />T Io NDI RTE CORPORATION O INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 11 FEDERAL -AGENCY' <br />DISTRICTS' <br />' II owner d UST Is a public agency, complete the following: nan a of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS1 GAS STATION ❑ 2 DISTRIBUTOR <br />✓ IF INDIAN <br />a OF TANKS AT SITE <br />E. P. A- I. D. a (opAmag <br />3 FARM 4 PROCESSOR ❑ 5 OTHER <br />RESERVATION <br />I OR TRUST LANDS <br />Zz.-6zw <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCYCONrACTPFRSnN 1AFrnunARv1-ectlneel <br />DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />c�rs�/ o.1J 5 - 9� 3 <br />NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />CZ 6') 5xi •lzi <br />O CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERAL -AGENCY <br />If. PROPERTY OWNER INFORMATION - IMUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ buabindkale INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />O v C `✓ <br />O CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERAL -AGENCY <br />MAILING OR STREET ADDRESS <br />✓ bot bin#kals � INDIVIDUAL <br />� LOCAL -AGENCY <br />0 STATE -AGENCY <br />—7 QC%oa GVuQ- <br />COflPOMTION O PARTNERSHIP <br />D COUMY-AGENCY <br />D FEDERAL -AGENCY <br />CITY NAME <br />s� lea(64— <br />STATE <br />ZIP CODEa <br />PONE WITH <br />AREA CODE <br />-.�,b ob <br />) <br />Zz.-6zw <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ buabindkale INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />O v C `✓ <br />O CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE 0 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 - O (� <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED <br />✓ boa bbdkate O 1 SELF INSURED 0 2 GUARANTEE [1:1 3 INSURANCE 0 a SURETY BOND <br />O 5 LETrEROFCREDIT [:D 6 EXEMPTION O 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: L ❑ II. ❑ 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 A SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY it JURISDICTION # FACILITY 0 <br />77-1 <br />2 / Go/qG <br />LOCATION CODE -OPTIONAL (CENSUS TRACTS -OPTIONAL aUPVISOR-DISTRICT CODE-OP710AL4L <br />11110 rvnM mw 1 of AU .UMrANItU PT AI LtAbl It) UN MUNI PtHM11 AHPLICAI ION - rUNM it, 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 />FORMA (393) � • Fgi0l63AAT <br />