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STATE OF CALIFORNIA .� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACIUlY NAME ,, '/I NAMEOFOPERATOR <br /> L O ont.0 4X (, e . <br /> ADDRESS <br /> NEAREST ROSS STREET PARCELA(OPTIONAL) <br /> D CLU hll-�-Q� � W <br /> CITY NAME <br /> STATE ZIP C DE SITE PHONE#WITH AREA CODE <br /> I/ BOX CA �cI ���" I <br /> TOINDICATE 0 CORPORATION O INDIVIDUAL O PARTNERSHIP CL2-tCCAL-AGENCY Q COUNTY AGENCY' STATE-AGENCY' ED FEDERAL-AGENCY' <br /> •II owner d UST lea ublic agency, S DISTRICTS' <br /> p 6 cy,complete the following:name of Su rvisor of tlNision,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#(apfimap <br /> 3 FARM ❑ 4 PROCESSOR OTHER O RESERVATION ` <br /> OR TRUST LANDS U <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> FNJGHTS: E <br /> ST,FIRST) PHONE♦ ITH AREA <br /> COD 2 DAYS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE <br /> / I <br /> L T,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> 2 7-$9-L <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OFADDRESS <br /> yy��FORMAT N <br /> S�u0 F � �IWl (0( 0 ✓il I'i <br /> MAILING STT AD KESSS �,yy ✓ Dox bindicale OINDIVIDUAL ALAGENCV STATE AGENCY <br /> Z �O CORPORATION = PARTNERSHIP COUNTY AGENCY <br /> CITU NAME•. vv— � FEDER4LAGENCV <br /> S STATE ZIP CODE O P ONE N ITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O W R CAR OF ADDRESS INFO ATION <br /> MAILIc <br /> o �fiOck rLotfrn (vi I <br /> NGO STR ADDRESS ✓ Eos 0Im.ale II INDIVIDUAL AL AUUCY <br /> O STATEAGENCY <br /> CORPORATION = PARTNERSHIP -1 COUNTYAGENCY FEDERAL-AGENCY YGN NAME <br /> STATE ZIP C�OppJEE /-� PHONE I WITH AREA DE <br /> t..v \ /`cr1CO <br /> 7 -1 50'CJ aC7W^-t <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questons arise. <br /> TY(TK) Hp 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box a Indicate 5,�"[SELF INSURED 0 2 GUARANTEE [=1 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT E-1 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 I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ III.0 <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 TITLE DATE MONTHIDAVrVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® of <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP7pNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM of UNLE53 THIS 13 A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 1 FOR6013A-H7 <br /> y3ry�� <br />