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/ • • 'ee V9 <br /> STATE OSTATE WATER URCES CONTROL <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ' <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> r . <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE - <br /> ONE ITEM OF INFORMATION ❑ 7 PERMANENTLY C SED SITE <br /> ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME- OPERATOR <br /> ADDRESS <br /> vAAl - I NEAREST CROSS 3TREET PAgCELA(OPrg <br /> /.¢rAG NAU <br /> CITY NAME <br /> �. STATE ZIP CODE <br /> BOX CA SITEPHONEN WITH AREACODE <br /> ✓ ®c � <br /> TO INDICATE CORPORATION <br /> L:] INDIVIDUAL EJ PARTNERSHIP Q LOCAL-AGENCY <br /> If owner of UST is aPublic agency,Wmplete the following:name of Supervisor of tliv1e n,Section,or office DISRICTS' -1COUNTY-AGENCY' STATE-AGENCY' -1FEOEMLAGENCY' <br /> TYPE OF BUSINESS operates the UST <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I,D.a(optimal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHERRESERVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS <br /> DAYS: NAME(LAST,FIRST) PHOEMERGENCYCONTACT PERSON (SECONDARY . <br /> NE K WITH AREA CODE J OPflOnel <br /> DAYS: NAME ,FIRST) <br /> PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE A'WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME I <br /> �,i?C-T.4xlAC3� u1 .�/ CARE OF ADDRESS INFORMATION <br /> oV rt S �J<.1 C <br /> MAILING OR STREET ADDRES <br /> ✓ box bandit to <br /> 165) Grj f7n�- O� Q INDIVIDUAL Q LOCAbAGENCY 0 STATE AGENCY <br /> CITU NAM�E�" a� l�CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY = FEDERALAGENCY <br /> J4 C rgAtiC 1., STATE ZIP CODE PHONE A'WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �SS6s <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ box pinEkau INDIVIDUAL <br /> (] LOCAL-AGENCY STAT AAGENCY <br /> CM NAME E�l CORPORATION 0 PARTNERSHIP 0 COUMY-AGENCY (] FEDERALAGENCY <br /> STATE ZIP CODE PHONE p WITH AREA CODE <br /> IV. <br /> TY(TK) HO 4 4_ _BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate O I SELFINSUREO Q 2 GUARANTEE <br /> i�5 LETTER OF CREDIT (]6 EXEMPTION L—J J INSURANCE O 99 OTHER L_j q SURETY BOND <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 /> I.❑ II.� 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 8 SIGNED) <br /> OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDKTION x <br /> FACILfTY M 1 <br /> LOCATK7N CODE -OPTIONAL CENSUS TRACTi -CPT/ONAL F6 `1 7— <br /> DIS <br /> I SUPVISOR- TRICT CODE -OPTIONAL <br /> 2 ?_ 2— �'!7v 50 <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 /> FORM A(3M3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU <br /> 0 0 <br /> F0R=3A-R7 <br />