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• STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD AVO PrV,'(a 7 Yc) Yym�o V •,x ca <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e <br /> J COMPLETE THIS FORM FOR EACH FACILITYISITE 1 N V -0 t g q 7 y <br /> ��tpOnYJ <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACILI NP.ME <br /> TL - _ NAMEOFOPERATOR <br /> ADDRESS <br /> NEAREST CRO SS STREET PAACEL#(OP7KINAy <br /> CITY AME <br /> �oi� STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CABOX <br /> TO NDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY-II owner of UST is a public agency,Conpl9e the following:name of Superv4or of dNbbn,ceclbn�or oil tal ce which 0 BATE AGENCY O FEllEML#GENCY' <br /> TYPE OF BUSINESS ❑ ❑ aperatec the UST <br /> 1 GAS STATION 2 DISTRIBUTOR ❑ RESERVATION <br /> #OF TANKS AT SITE E.P.A. I.D.#(�Bn N) <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST I. <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS; NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM <br /> CARE OF ADDR INFORMATION ff <br /> iGSOn( �Z 9 <br /> MAILING OR STREET DRESS ' <br /> ✓ lroxbintlkMe 0 INDIVIDUAL LOCAUAGENCV <br /> !O 0 CORPORATION (] PARTNERSHIP 0 STATE-AGENCY <br /> IN ME O COUNTY-AGENCY � FEDERAL-AGENCY <br /> C <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAN10FOINNtK <br /> f __ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET DRES <br /> / ✓CORPiRATIO 0 INDIVIDUAL O LOCAL-AGENCY f STATE- <br /> AGENCY <br /> CITY NAM IE CORPORATION (] PARTNERSHIP O COUNIYAGENCY FEDEMLAGENCV <br /> Gad STATE I ZIP CODE ' / PHONE 0 WITH AREA CODE <br /> AR <br /> IV.BOD OF EQUALIZATION UST STORAGE <br /> FEE ACCOUNT NUMBER•Call(916)322-96697 questions arise. <br /> TY(TK) HQ [4T4_-]- <br /> V. PETROLEUM UST FI�N—A—NCICIAL RE�SPONSuIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hoxblMkate I� 1 <br /> 11, ;1 Q 2 GUARANTEE ] INSURANCE <br /> ED <br /> O 5 LETTEROFCAEDIT 0 6 EXEMPTION x SURE YBOND <br /> 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNEfl'S NAME(PRINTED 8 SIGNED) OWNER'S TOLE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY p!v 804 <br /> COUNTY# <br /> JURISDICTION# e <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL <br /> OC. <br /> +-� SUPASOR-DISTRICT CODE -OPTIONAL <br /> �?L A\ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 19 0 <br /> FOR0033AR7 <br />