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• ecw• e <br /> STATE OF CAUFOHWA <br /> v l <br /> STATE WATER RESOURCES CONTROL BOARD i S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °w <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `"1O""•� <br /> MARK ONLY O O NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SIT q <br /> ONE NEM Q 2 INTERIM PERMIT El 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE -I <br /> I. FACILITYISITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> - <br /> AWRESS NEAREST CROSS STREET PARCEL a(OPTN)NAU <br /> CITY NAME $TATE ZIP CODE SITE PHONE I WITH AREA CODE <br /> G o�� CA 4 Zia <br /> BOX 0 CORPORATION INDIVIDUALDISTRICTS'T DICATE LOCAL AGENCY O COUNTYAGENCY' O STATE AGENCY' O FEDERAL-AGENCY' <br /> •N owner aT UST Is a pubic sgenq,oortpleu Na loiovAng:name of Supervisor of division.section.or orrice v hIch operate•the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR RE 1 IF INDDION a OF TANKS AT SITE E.P.A. I.D.a(rplimaq <br /> J 3 FARM A PROCESSOR LIT <br /> 6 OTHER OR TRUST LAN <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS. NAME(LAST,FIRS PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREETAODRESS ✓ box bhliP.aM O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> ���� 30Q F6 CD CORPORATION O PARTNERSHIP O COUNFY-AGENCY E:l FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 957-y/-/ 9)D <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ,�...... CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bOrbxd¢aN (] INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 p CJ6 O CORPORATION [7:1 PARTNERSHIP Ij COUNTY Ar O FEDERAL AGENCY <br /> CITY NAME STATE 21P CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- - 1--F] -r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �bWkLs CD 1 SELFINSURED O 2 GUARANTEE O 3 INSURANCE D ASURETYBOND <br /> D 5 LETTEROFCREDIT 0 e EXEMPTION O MOTHER <br /> _ _— <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.Q IL III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,LS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION At <br /> LOCATION(RODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OP <br /> 07 1 03. W 57-D <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 /> FORM A(393) FpgW2ANi7 <br />