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spun e <br /> STATE OF CALIFORMA hr ...... <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A p� '• <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> EcARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION p 7 PERMANENTLY CLOSED SITE <br /> NE ITEM 2 INTERIM PERMIT E:1 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> � I <br /> 1. FACiLITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATO <br /> ADDRESS NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> CIN NAME <br /> STACTjE4 ZIP OD v� SITE PHONE S WITH <br /> TH AREA CODE <br /> ✓ Box <br /> TO INDICATE RPORATION IJ INDIVIDUAL i=PARTNERSHIP LOCAL-AGENCY ®COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL•AGENCY' <br /> II owner of UST Is a public agency,complete the following:name of Supervisor of division,sact on Dor ISTRI C S' <br /> ch <br /> Operator the UST <br /> 1 GAS STATION <br /> Q Q 2 DISTRIBUTOR R SEIRVATDION #OF TANKS AT SITE E.P.A. 1.0.#(optional) <br /> TYPE OF BUSINESS <br /> [] 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS GSL- 0clf> <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST?FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / J ✓ box to Indicate 0 INDIVIDUAL © LOCAL-AGENCY <br /> 112x ��l IG' ORPDRATION ® PARTNERSHIP � FEDERAL-AGEATE NCY I� COUNTY-AGENCY � FEDERAL-AGENCY <br /> CITY NAME T`AIT�E^ ZIP CODE P}iONE#WITH AREA CODE <br /> a �L D � G''x"i�:• <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A1--,- <; <br /> MAILING OR STREET ADDRESS ✓ box No indicate <br /> � INDIVIDUAL <br /> LOCAL AGENCY [__1 STATE-AGEiCY <br /> CORPORATION <br /> E�71 PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ Q 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box fa indicate [__1 1SELF-INSURED Q2 GUARANTEE <br /> 3 INSURANCEI�4 SURET�BOND <br /> 0 5 LETTEROFCREDT 0 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&LLING: I. 11.0 III. <br /> THIS FORM!HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T14E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> =_GGOOE � <br /> # JURISDICTION# FACILITY <br /> CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br /> IL g <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE 01 INFoAmAII ONLY, <br /> FORMA(3A33) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM <br /> • FORI <br />