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& • eW- <br /> �� C <br /> STATE OF CALIFORNIA ti <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W.,� :8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :� , ; <br /> COMPLETE THIS FORM FOR EACH FAGUTYISITE `'coon+" <br /> I NEW PERMIT 3 RENEWAL PERMIT a CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE fL <br /> MARK ONLY D "\ <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA . FACILITYNAME NAM <br /> rED ERATOefl <br /> AD RESS NEAFJEST CRSTREET MC A(OPfpNAq <br /> Zile, u LM: 4. <br /> CITY M STATEP CODE SITE PHONE#WITH AREA CODE <br /> S ZI <br /> CA S o <br /> ✓INDICATE CORPORATION Q INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY COUNTYAGENCY' O STATE-AGENCY' Il FEDERAL-AGENCY' <br /> OX I <br /> TOINDISTRICTS' <br /> II owner of UST is a public agency,complete the following:name of Supervisor of division,seclbn,or office which operates the UST <br /> TYPE OF BUSINESS EjWrl GAS STATION 2 DISTRIBUTOR0 RESERVATION✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apfional) <br /> q <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUSTLANDS .J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS NAME(LAST.FIRS PHONE#WITH AREA COD DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a 4•r 6 <br /> NIGHTS: NAME(LAST,FIRST) P ONE#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 /> MAILII G, R STREETA DRESS / ✓ indicate O INDIVIDUAL I� LOCAL AGENCY 0 STATE-AGENCY <br /> GJ` VpA/, A••`l/ CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �c 4L�hn 2� 3 6 s <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED WNER CARE OF ADDRESS INFORMATION <br /> f' <br /> MAILING STREET ADDRESS ✓ botbindicate 0 INDIVIDUAL L-1LOCAL-AGENCY =STATE-AGENCY <br /> w CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STF* I ZIP CODE_ PHONE#WITH ARE CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arite. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate O t SELF-INSURED I=1 2 GUARANTEEI� 3 I/NgURANCE =4 SUREN BONG <br /> =5 LETTER OF CREDIT =5 EXEMPTION I,i UTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECKONEBOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 11.[:] 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/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVIS5 <br /> ii- ISTRK:T CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(353) 0 <br /> 0 FOR0033AR7 <br />