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• STATEOFCALFORWA • ^�--- ,• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACHFAGLITY/SITE <br /> MARK ONLY O t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT p 6 TEMPORARY SITE CLOSURE _. <br /> r <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> F�r,L <br /> ADDRESS ^ �/ NEAREST CROSS STREE�7� � f( �� PARCEU IOPTgNAIJ <br /> CITY NAME <br /> Lo ^ STATE ZIP CODE_ ,� SITE PHONE#WITH AREA CODE <br /> ✓ BOX CA Z7`,�/ <br /> TOINDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' O FEDERAL-AGENCY' <br /> It owner of UST lea public a DISTRICTS' <br /> p agency.complete the fpllowin :name of Supervisor of tlHisbn,sectnn,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.#([primal) <br /> 0 3 FARM Q 4 PROCESSOR 6 OTHER RESEflVATION <br /> Ofl TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AME(LAST,FIRST) P NE# ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WI�AREACIODE <br /> G�.AT/l Z� ZZZ-82i � <br /> NIGHTS: NAME(LAST,FIRST) ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WI <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMicale <br /> 7 �� Gv A 0 INDIVIDUAL LOCAL AGENCY EDSTATE-AGENCY <br /> / <br /> - 1(+G� ,4t%[4 (]CORPORATION = PARTNERSHIP t] COUNTY AGENCY [—I FEDERAL-AGENCY <br /> CITY N�AMpE STA1L. 71PrnnP \ HONE WITH AREA CODE <br /> li�_IT ! V <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NA E OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I ✓ box blMbale O INDIVIDUAL 0 LOCAL AGENCY <br /> �, (t\JI � STATE AGENCY <br /> / iI CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITU NAME STATE ZIP COD <br /> r-. HONE WITH AREA CODE <br /> G ZED � 222-82i t:�, <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 to Indicate 0 1 SELF-INSURED E:1 2 GUARANTEE 0 3 INSURANCE <br /> E-15 LETrER OF CREDIT O 6 EXEMPTION D I SURETY BOND <br /> O N6 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 FOO LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THEBEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAM E(PRINTED B SIGNED) OWNER'S IIILE DATEMONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION v FACILITY 0 5T <br /> x LOCATION CODE -OPT/OA/AL CENSUSTRACTN -OPTIONAL :011 z7 <br /> CO DE -OPTpNAL p� <br /> �� z b <br /> J THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) <br /> rr OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ���''(� 0 F0110667Ap7 <br />