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• '�� VII <br /> STATE OFCALIFORNA • .r <br /> STATE WATER RESOURCES CONTROL BOARD i '0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE „o ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDflESS NEAREST CROSS STREET PABCELY(OPTIONAu <br /> CIN NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE O CORPORATION (]INDIVIDUAL [=]PARTNERSHIP I] LOCALAGENCY COUNT .AGENCY' <br /> DISTRICTS' O STATE AGENCY' (] FEDERAL If owner of UST Is a public agency,mmplele the following:name of Supervisor of o"ion,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ -/ IF INDIAN NOF TANKS AT SITE E.P.A. I.D. plionap <br /> O 3 FARM ❑ 4 PROCESSOR 5 OTHER RESERVATION <br /> #(o <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N 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 ADDRESS ✓ box blMicale O INDIVIDUAL 0 LOCALAGENCV <br /> STATE.AGENCV <br /> (] <br /> CIN NAME CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY (] FEDERAL AGENCY <br /> 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 biMisale D INDIVIDUAL O LOCAL AGENCV <br /> O STATE AGENCY <br /> CITYNAME CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE j <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [-4T4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box birNbab I SELF INSURED E-1 2 GUARANTEE ❑ 3 INSURANCE <br /> O 5 LETTEROFCREDIT Q 99 OTHER <br /> 6 EXEMPTION D d SURE BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank 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.❑ -- <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 B SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONmAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODEE -OP77O� <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 /> FORMA(3/93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • <br /> 0 <br /> FOR0033AN7 <br />