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STATE OF CALIFORNIA ^^ <br /> b <br /> STATE WATER RESOURCES CONTROL BOARD <br /> ` 2 UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , ,e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY T NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION X,,7 PERMANENTLY CLOSF-O-SITE <br /> ONE TEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILFTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME (4M NAME OF OPERATOR <br /> ADDRESS , r NEARESTCROSS STREET PARCEL#(OPTIONAL) <br /> 33 I <br /> CITY AMESSTC# ZIP �O r SITE PHONE a WITH AREA CODE <br /> T 10 Np AC TE (]CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL AGENCY O COUNTY-AGENCY- O STATE-AGENCY' O FEDEMLAGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a public agency,corrpl the foliowing:name of Supervisor of division,seelgn,or office which operate the UST <br /> ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.a loPl/mal) <br /> TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opllonel <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAM E(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 4 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ( ) I • <br /> //Y CDAREOF ADDRESS INFORMATION <br /> OR <br /> MAILING9 .1 box bindkAU C::] INDIVIDUAL <br /> L LOCAL-AGENCY STATE-AGENCY <br /> CPoRATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> T ZIPHONE s WITH AREA CODE <br /> CIN NAME QF <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `�box windic a 0INDIVIDUAL O LOCALAGENCY STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP ED cOUNrY-AGENCY [] FEDERAL AGENCY <br /> CITY NAME STATE ZIP 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) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Dov biMkale O 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> = 5 LETTER OF CREDIT O B ExEMPnON Bg 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: L El II-tK III.0 <br /> 1 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'STITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION Y FACILITY• <br /> LOCATION CODE-OPTIONAL CENSUS TM TC -OPINA14L SUPVISOR-7TRICTCODE •(WTIONAL <br /> C (i�1 <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(393) FOR=3AA7 <br />