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STATE OF CALIFORNIASTATE WATER RESOURCES •�cwa-e <br /> OL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ' <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 3 NEW PERMIT �tooar.• <br /> ONE REM REM 3 I PERMIT ❑ 6 CHANGE OF INFORMATION ❑ <br /> ❑ 2 INTERIM PERMIT Q d AMENDED PERMIT T PERMANENTLY CLOSED 317E <br /> I. FACILITY ITE INFORMATION&ADDRESS•(MUST BE e TEMPORARY SITE CLOSURE <br /> DBA OR FACT TY AME COMPLETED) <br /> NAMEOFOPERATOR <br /> ADDRESS C� <br /> v6/>/ i NEAREST CROSS STREET <br /> CITY NAME �/Ji^�. PARCEL#(OPIONAL) <br /> T STATE ZIP CODE <br /> CA ITE PHO E i WITH AREA CODE <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL " E ^,7 <br /> If a Gf d UST lea ub5e 0 PARTNERSHIP 0 LOCAL-AGENCY I <br /> P agenry,o9 pa 1Ne following:name of Supervbm of dNkbn,segbn,DIS DISTRICTS <br /> whbh _ �m-AGENCY' �y7p7E,AGENCV <br /> TYPE OF BUSINESS 'Pesten the UST 0 FEDERAL-AGENCY' <br /> ❑ ' GAS STATION ❑ 2 DISTRIBUTOR <br /> 3 FARM ❑ ✓ IF RINDIAN apF TANKS A7 SITE E.P.A. I.D.[� 4 PROCESSOR Q b OTHER RESERVATION (9NArwI/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUSTLAND.R <br /> DAYS' NAlf1E LAST,FIRST) EMERGENCY CONT <br /> Uzi^+i71 PHONE#WITH AgEA CpDE ACT PERSON (SECONDARY)..l <br /> (LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE PHONE i WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> G <br /> CARE OF ADDRESS INFORMATION <br /> OR STgEET <br /> MOAILIADORES <br /> vV/ (-(/ ✓Ew bNOkm O INDIVIDUAL CITY NAME J O COgPpRAnON 0 PARTNERSHIP 0 LOCAL-AGENCY (_]STATE-AGENCY <br /> GO/�� STA ZIP COD/E O COUNTY-AGENCY O FEDERAL-AGENCY <br /> %ZL PHONEi WITH AgEA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEO OWNER <br /> MAILING OR STREET ADDS CARE OF ADDRESS INFORMATION 0 INDIVIDUAL <br /> E --- <br /> box 1 <br /> CITY NAME 0—PORA�N 0 LOCAL-AGENCY 0 STATE AGENCY <br /> 2 <br /> Laos STATE O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> 1P CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916 22-9If questions arise. <br /> TY(TK) HO 4 4_ _ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ben b 01 SELF-INSURED <br /> 0 5 LEITER OFCgEDT 0 2 G E 0 3 INSURANCE <br /> O B EXEMPTION <br /> ON 0 99 OTHER O I SURE Y BOND <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 /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TO AND CORRECTII.❑ <br /> OWNER'S NAME(PRINTED A SIGNED) <br /> OWNER'S TfTLE <br /> DATE MONTHIDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# <br /> JURISDICTION# <br /> FACILITY/#• 2 '/ <br /> LOCATION CGDE -OPTIONAL CENSUSTflACTi-OPTIONAL O t7 <br /> FEE <br /> Z J. L� S�M�•DISTRICTCODE -pow <br /> THIS FORM MUST 8E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF 3-ITE-IN--FORMAT <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />