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• • eWR <br /> STATE OF CALIFORNIA <br /> GSTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND + <br /> STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FA LITYISITE •���„a.�,. <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CL <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE C <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA F ILITY NAME rn NAME OPE <br /> cxf <br /> ADDRE NE CRO T E PARCEL a(OPTIONA0 <br /> CITY NA + STATE ZIP V ''W SITE PHONES WITH AREA CODE <br /> Wf L�,�N(rti CA <br /> T Io NDIATE CORPORATION 0 INDIVIDUAL (]PARTNERSHIP O LOCAL AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY• ED FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a public agency,complete the lollowing:name of Supervreor of th ision,sactbn,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIAN SOF TANKS AT SITE E.P.A. I.D.#(cpticnal) <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER RESERVATION <br /> OR TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Dox blMka4 INDIVIDUAL LOCALAGENCV lJ STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP O COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CO <br /> OE 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 biMka4 Q INDIVIDUAL D LOCAL AGENCY O STATE AGENCY <br /> ED CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONES 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- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlkas, I SELF INSURED M 2 GUARANTEE O 3 INSURANCE E=1 4 SURETYBOND <br /> 5 LETTEROFCREOIT =6 EXEMPTION O B3 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. ILO 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&SIGNED) OWNER'S TITLE DATE MONTHIDAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDKTION# FACILITY# <br /> 1510 1,31 1 '12 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL ,q <br /> Al— <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMrr APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR! K jjj{{{ <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANEGULATIONS <br /> FORMA(3/e3) s `/�o�/� FOROD73AA7 <br />