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• • 'V60VP <br /> / STATEOFCALIFORNIA <br /> 1 STATE WATER RESOURCES CONTROL BOARD <br /> yl / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `•x�.eae" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE .53 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY\NAME I NAME OF OPERATOR <br /> VN 7—k "C <br /> ADDRESS S"T NEAREST CROSS STREET PARCEL#(OPrIONAU <br /> CITU NAMEl �^ STACA ZIP�� Z I c` SITE PHONE#WITH AREA CODE <br /> ,f,— G <br /> ✓ BOX � <br /> TOINDICATE D CORPORATION l� INDIVIDUAL 0 PARTNERSHIP /� D�gL-AGENCY O COUNTY-AGENCY• l� STATE-AGENCY' O FEDERAL <br /> If owner of UST Is a public agency,compiete the following:name o1 Supervi or of drAslon,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ RE/ IF INDIAN <br /> DDION A OF TANKS AT SITE E.P.A. I.D.X(oplional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR E:,p­S't5TER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE xx WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMbate [-I INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> D CORPORATION l= PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL 0 LOCAL AGENCY O STATE AGENCY <br /> D CORPORATION PARTNERSHIP 0 COUNTY AGENCY l_:3 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate 0 1 SELF INSURED [-12 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDT 0 6 EXEMPTION D 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: U❑ 11. 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&SIGNED) OWNER'S TITLE DATE MONTWDAYrYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• <br /> K 2S Iz- L o y <br /> LOCATION CODE -OPTIONAlDL CENSUS TRACT* -OPTIONAL SUPVISOR- ISTRICT CORE -OPTIONAL <br /> Zz <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS LR 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(3131) �`.`._', WRa033A-R7 <br />