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STATEOFCAUFORMA • �� +,. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� <br /> y COMPLETE THIS FORM FOR EACH FACILITY/SITE � o�„oe„,�'e <br /> 1 NEW PERMIT <br /> MARK ONLY Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR ACILyTV NAME NAME OF OPERATOR <br /> cry f- <br /> ADDRESS NEAREST CROSS STREET PARCELIP(OPTIONAL) <br /> CITY NA E STATE ZIP GODE SITE PHONE#WITH AREA CODE <br /> I/ BOX oD CA <br /> TOINDICATE EJ CORPORATION I71 INDIVIDUAL [::] PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY' O STATE AGENCY' O FEDERAL-AGENCY' <br /> H owner N UST Is a public agency,complete the following:nae of Superv'sor of tlNlebn,section.DISTRICTS n,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION F__j 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM 4 PROCESSORRESERVATION <br /> `�';-OTHER OR TRUST LANDS <br /> EMERGENCY-CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE.OF/1 KESS INFO ATION <br /> MAILING OR SGTREET_AOD E�SS/�q ✓ icor bbdbas � INDIVIDUAL � LOCAL-AGENCY O STATE-AGENCY <br /> 4 / / "T'i`r1 V 0 CORPORATION Ej PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE a WITH AREA CODE <br /> /a10 clo <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEO ERI C CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY = STATE-AGENCY <br /> 6 G Ed�s9 =CORPORATION O PARTNERSHIP Q COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATIE,4 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate L�] 1 SELF-INSURED L-1 2 GUARANTEE 3 INSURANCE <br /> 0 1 SURETY BOND <br /> O 5 LEREfl OF CREDIT =S EXEMPTION O W 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/VEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m C�7 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRAGI -OIPTN)NAL SUPVISOR-DISTRICT CODE -OPTXINAL <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 /> FORMA(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORU033ANT <br />