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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 't5 c"�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t 'in <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSEoal— <br /> DBA <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)"FACILIT7YNAME NAME OF OPERATOR <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4d 4 W�� STATE ZIP CODESITE PHONE#WITH AREA CO cARATION O INDIVIDUAL Q PARTNERSHIP Q LOCA4AGENCY OCOUNTY-AGENCY' QSTATE-AGENCY' O FEDERAL- ENCY' <br /> HawnerM USTsa oblba P S W DISTRICTS <br /> P genq,cam'ale Ne lolbwb:rwlb ofs ernsolal tlnabn,sepion or office which the UST <br /> TYPE OF BUSINESS —71 <br /> 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN l#OF TANKS AT SITE <br /> ❑ 3 FARM O # PROCESSOR5 OTHER ❑ RESERVATION <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> —� DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �D PHONE#WITH AREA CODE <br /> N A T, IRST) PHUNE#WITH AREA Coot NIGHTS: NAME(LAST,FIRST) PHONE#WITH-AREA E <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bola r DINDNIWAL 0LOCAL-AGENCY <br /> = STATE A( <br /> CITY NAME CORPORATION O PARTNERSHIP QCOUNTY-AGENCY = FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> JII <br /> NK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Luz i— <br /> MAIL NG ORSTREET ADORES Dox to e • Q INOIVIWAL <br /> I ' /n� O L -AGENCY 0 STATE-AG NCY <br /> s� f�CORPOMTION I]PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-GENCY <br /> CITY NAM 1 STATE ZIP CODEPHONE p WITHNIR CODE <br /> 3 <br /> IZAIIGN UST STORAG-F FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. j <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to Wicale SF.INSURED Q 2 GUARANTEE =3 INSURANCE Q d SUREIYBONO <br /> S LS EXEMPTION O 7 STATE FNDO�BSTATE FUND dCHIEF FINANCIAL OFFICER LETTER 09STATE FUND BCERTIFICATE OfDEPOSIT =110 LOCAL GOVT.MECHANISM <br /> O B9OTHER <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: I.X II.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTHVDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> 3 -- <br /> COUNTY# JURISDICTION# FACILITY# <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- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6-95) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI STORAGE TANK REGULATIONS <br /> a 9 7 <br />