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• STATEOFCAUFORMASTATE WATER RESOURCES CONTROL BOARD <br /> .epO"" <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> ,Q�, ao <br /> COMPLETE THIS FORM FOR EACH FACILITY/SfTE -� '' <br /> MARK ONLY ❑ 1 NEW PERMIT ^ °�roon�" <br /> ONE REiM ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> L FACILrT /SITE INFORMATION&ADDRESS-(MUST BE COMPLETED S TEMPORARY SITE CLOSURE <br /> ii0 <br /> DBA OSSACIUITV pME NAMEOFOPERATOR <br /> ADD REESSS/'L�lAL <br /> //I�I1 G{/, / NEAREST CROSS STREET PARCEL# <br /> CITY NAME �4/LT•� (OPTIONAL) <br /> ' STATE ZIP CODE <br /> CA TE PHO E#WITH AREA CODE TO NgpATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCYC-1 <br /> N owner of UST is a Publlc agency,mrlplele the following:name of SuPenrborof EHlebn,section DISTRICTS- kh OCOUNTY-AGENCY' STATE-AGENCY' <br /> TYPE OF BUSINESS FEDERAL <br /> ❑ 1 GAS STATION °Parolee INe UST <br /> ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.# <br /> 3 FARM ❑ 4 PROCESSOR RESERVATION (cplional) <br /> ❑ 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NnuE Lns'�T.FIRST) EMERGENCY CONTACT PERSON (SECONDARY). <br /> PHONE#WITH AREA CODE ) OPt101181 <br /> Z�` `/2 DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) / PHONE i WITH AREA CODE <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION. MUST BE COMPLETED <br /> NAME <br /> q�� <br /> ITYI.y"f CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRES <br /> ✓ box biMbale 0 INDIVIDUAL (] <br /> CITY NAME L (]COgPoRATION = PARTNERSHIP LOCpL.AGENCY �STATE-AGENCY <br /> ZIP CODE <br /> GUQ STAT O COUNTY AGENCY (] FEDERAL-AGENCY <br /> PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) �Z <br /> NAMED OWNER <br /> ,i-. CARE OF ADDRESS INFORMATION <br /> MAILING OR STREEI'gpDRE <br /> // /.�� ✓ box biMbaa — INDIVIDUAL <br /> O LOCALAGENCY Q STATE AGENCY <br /> CITY NAME 7 0 CORPORATION 0 PARTNERSHIP <br /> Lva2 ZIP STATE COUMVAGENCY 0 FEDERAL CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-all(916)22-9�if questions arise. <br /> TY(TK) HQ 4 4_ _ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxb11dule ] 1 SELFINSURED <br /> � <br /> 0 5 LETTEROFCREDIT 2 GUARANTEE L_j 3(OTHER CE <br /> Q 6 EXEMPTION 0 93 OTHER I SURETYPOND <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.[:j II.❑ III.❑ <br /> OWNERS NAME(PRINTED 8 SIGNED) <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S TITLE <br /> DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONALQTI <br /> CENSUS TRACT# .QeTIONA( / <br /> Z_3 Z� 9UPVISOR-INSTRICT CO[)E -OPTpNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B UNLESS THIS IS A CHANGE OF INFDRUATIONY7 3D 9NL <br /> FORM A(3N3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS ONLY <br /> 0 0, FOADOXIAA7 <br />