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• f.E60Ve - <br /> w' <br /> STATE OF CAL1FOi1WA 'o <br /> STATE WATER RESOURCES CONTROL BOARD W u n <br /> I UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM F--j 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE Z <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> WTOINDICATE <br /> NAM FOPERAT R <br /> NEA OR TRUE C�— PARCELe(OPfgNAq <br /> STATE ZIP SI P E I A <br /> CA <br /> INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 0 COUMV-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •H wr,er of UST is a public agency,wffplete the foij"Ing:name of Supervisor of dNBbn,section,or office Which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TAyK$AT SITE E.P.A. I.D.i(optimal) <br /> O RESERVATION �(/J_ <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <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 /> MAILING OR STREET ADDRESSpuz ✓ bcxbinEka& 0 INDIVIDUAL ED LOCAL-AGENCY D STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0iMkale = INDIVIDUAL O LOCAL STATE-AGENCY <br /> I�CORPORARON O PARTNERSHIP =COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST <br /> STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -T V I r�'T-1-L14 t I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHODS) USED <br /> ✓ box blMkale O l SaRNSURED UARANTEE O 3 INSURANCE O A SURELY BOND <br /> O 5 LETTER OF CREDIT 5 EXEMPTION 0 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: I.� II.0 IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAY/YEAP <br /> LOCAL AGENCY USE ONLY <br /> C�L�O�/gU�J'�NL/�TT�`Y-JIB# JURISDICTION <br /> � # FACT <br /> pf\ <br /> LOCAT DE -OPTIONAL CENSUS TRAU1 OP b SUPVISOR-DISTRICT 770ML (/ <br /> -17 <br /> 11 2311-,7-1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLE/SSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING T,HE UNDERGROUND STORAGE TANK REGULATIONS FON9033AR7 <br /> FORM A(393) 1 1 11 I <br /> 1.ill <br /> r <br />