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STATE OFCAUPORNIA c <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A `m� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7A01OPTIONk) <br /> Y CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> SADDRESS <br /> NAME OFOPE TOR <br /> N REST CROSS STREET PL) <br /> c STATE ZI E SAgEA CODECA 5 jTOINOCATE CORPORATION (]INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' O ST0 FEDERAL-AGENCY'DBTq CTS' <br /> H amer d UST le a public agency,mmplae the toAowNg:name d Supervleor d dNleIon.section.or of ice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN A OF TANKS AT SITE EcxuA mf) <br /> 3 FARM d PROCESSOR 6 OTHER <br /> ❑ ❑ RESERVATION <br /> OR TRUST LANDS <br /> 1i CA! <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> 0 VS: NAME(LAST FIRST) PONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE=CODENI�TS: NAME(L ,FIRST) a H WIT ARE E / NIGHTS: NAME(LAST,FIRST) PHONE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETEC/D) <br /> NAME ` ` o CAREOFADDRESS INFORMATION <br /> N <br /> MAILING OR STREET ADDRESS ✓Dox binokale � INDIVIOVAL O LOCAL-AGENCY ED STATE-AGENCY <br /> OE q (]CORPORATION (6 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NA Y ST ZIP CODE PHONE WIT A EA CODE <br /> S 2!Z2 4o <br /> - <br /> III. TANK OWNER INFOR TION•(MUST BE COMPLETED) <br /> N EOFO R / _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binokau INDIVIDUAL LOCAL AGENCY 0 STATE AGENCY <br /> Zoo/ O CORPORATION LX PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME / . ST ZI ODE I_ ` PHONE N WITH AREA CODE <br /> IV.BOARD bF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)33222-9669 it questions arise. <br /> TY(TK) HQ F4-14--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbiadkaN 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> 0 6 SURETY BOND <br /> D 5 LETTER OF CREDIT O S EXEMPTION (] 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: 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 /> 0D)OW R' ME( INTEDa 1 <br /> OWNE E DATE MONTHID YNE <br /> LOCAL AGENCY USE ONLY' <br /> COUNTY# JURISDICTION# FACILITY# 7Zs-7 <br /> ED alollo I 18 <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> N 9 b <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SffE ORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A("3) • <br /> • FORm3A-R7 <br />