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acW- e <br /> STATEOFCAUPORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACHFACILITY/SrTE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARESTCROSSST EET PARCEL#(OPrIONAL) <br /> � <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Gorrr CA 45211b <br /> TI/ BOX 0 CORPORATION INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCY' D STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If w er of UST Is a public agency,complete the following:nana of Supervisor of dNisbn,aeallon,or office Which Operates the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR = <br /> RESERVATION <br /> IF INDIAN <br /> A OF TANKS AT SITE E.P.A. 1.D.#fapt/maq <br /> Q 3 FARM Q A PROCESSOR 5 OTHER ORTRUSTLANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST FIRST) PHONE a WI H AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2 GY C �3 -Z 3S- <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 /> G <br /> MAILING OR STREET ADDRESS ✓boa bindicab 0 INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> p e4". 0 CORPORATION 0 PARTNERSHIP 0 COUNrYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME FOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRREESISS ✓ boa blrAkab 0 INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> CC 0 CORPORATION 0 PARTNERSHIP 0 COUMY-AGENCY ID FEDERAL-AGENCY <br /> CVNAME STATE IZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQ 4 4- - <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa bindicats 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE A SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 0 99 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.❑ 1 E <br /> 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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• �.-- <br /> LOCATIONDECODE -OPTIONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISPAICT CODE -OPTpNAL <br /> - Zo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(393) <br /> OWNER MUST FILE THIS FORM jjTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F(Ifl00.73N17 <br /> r <br />