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_ � • a <br /> STATE OF CAUFORJIA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE — <br /> ONE rTEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION Ill ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA O��ACILIQN E C� <br /> F[.•J �C PARCEL#(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRESS/ <br /> 76 CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> C CA D P o <br /> ✓ gCX �DISTRCGENCV <br /> TO I/ Box <br /> O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP r// �LOTRICT3' �COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> It owner d UST is a public agency,complde the following:name of Supervisor of dNisle ,a cUen,or oince whbh operates the UST <br /> TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.a(optlanal) <br /> ❑ RESERVATION 3 <br /> ❑ 3 FARM ❑ 4 PROCESSOR X.5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAVS: NAME LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> ` ADE WITH AREA CODE J NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> LNAME ✓ bor bindsale INDIVIDUAL � LOCAL-AGENCY STATE-AGENCY <br /> REET ADDRESS0 CORPORATION 0 PARTNFASXIP O COUNfY-AGENCY FEDEPAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 7T./ <br /> E OF ADDRESS INFORMATION <br /> avrL e a� r 1 <br /> MAILING OR STREET ADDRESS boob WbaU OINDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCYCORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCYTE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa binObale D I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 E%EMP ION !#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: <br /> n.❑ BI.❑ <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 MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY O- I A3 to <br /> COUNTY# JURISDICTION# FACILITY# <br /> ,� CLQ CT17 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -g TIONAL SUPVISOR•DISTRICT •C'P710NAL <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 <br /> STORAGE TANK REGULATIONS '7y�FORDO33A-R7 <br /> FORMAM) 0 6/ if (y�— s'_ y�- �„ltJ <br />