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C <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD +„� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , ;s <br /> COMPLETE THIS FORM FOR EACH FACILITYISITIE `�4/pee•• <br /> MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM F 2 INTERIM PERMIT L:j 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) <br /> o Sc✓�L <br /> CITY NIIIME STATE ZIP CODE SITE PHONE#WITH AREA GOD <br /> tea= CA 95ZBOX <br /> �� Iia 333- 6�0 <br /> TO INDICATE I�CORPORATION 0 INDIVIDUAL O PARTNERSHIP 4N DISTRICTS' O COUNTY-AGENCY' E-1 STATE-AGENCY, I� FEDEML-AGENCY• <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#toplicnal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR PC 5 OTHER Oq TRUST LANDS ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME( FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G or Loo <br /> 91�INGOR STREET ADDRESS / ✓ boxbindYab 0INDIVIDUAL LOCAL AGENCY OSTATE-AGENCY <br /> / '✓D <br /> 13O D D.(-j CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE _ PHONE#WITH AREA CODE <br /> OBJ CA 95Z�f L� ucJ 9J3i— �j70�j <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Gir aim Lo%J <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0INDIVIDUAL 0 LOCAL AGENCY O STATE-AGENCY <br /> 0 13O 3c-v6 CORPORATION O PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Lori m �75?_ N <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4T4_ - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box Itirdbale E=1 1 SELF INSURED E-1 2 GUARANTEE = 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTEROFCREDT =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 BILLING: L= 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 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILfTY IF <br /> mijS ° O 5J 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -0^7pNAL <br /> 07 -Z3 . 3z0 <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 /> FORMA(393) • FOR0037AA7 <br /> isa101kv-1I <br />