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1 <br /> • e w <br /> 9TATSOFCAUFORNIA .' ;� <br /> STATE WATER RESOURCES CONTROL BOARD 8 <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION a FORM A a, <br /> COMPLETE THIS FORM FOR EACHFACILITY/SITE '���ea+` <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FA ILITY NAM J� NAME OF OPERAT <br /> AD E J LY/1/r1 NEARE 00STR / PARCEL#(OPTIONAL) <br /> /✓ �� V12TT! <br /> CITU N✓A STATE ZIPCOOL. SITE PHONE a WITH ARRA CODE <br /> CA pI,720 <br /> TO INDICATE O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,conplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ R,1 IF INDIAN 1 <br /> SERVATTION A OF TANKS AT SITE E.P.A. I.D.a(goflanali <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box birxlkab 0 INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP = COUNTY-AGENCY [--] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 bindkaw 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZJP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO R 4 - 2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbinUkate (]i SELF-INSURED 2 GUARANTEE ED 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDR O S EXEMPTION O go 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.❑ IL❑ 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 a SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION If FACILITYN <br /> 3ffi PA 111 <br /> LOCATION DE -OPTIONAL CENSUS TRACT-�;TIJAA SUPVISOR-qL8 CODE- <br /> ) 1illii�� !V7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSfrHIS 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(393) FOR0039,1197 <br />