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a <br /> STATEOFCAUFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM ACOMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT D 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT E::3 S TEMPORARY SITE CLOSURE pZ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DPA 09 FACI ITY NAME i NAME OF OPERATOR <br /> ' G <br /> ADDRESS NEAR STCROSSSTREET PARCEL%(OPTIONAL) <br /> CITY NAME STATE ZIP CODE 3FE PHONE%WITH AREA CODE <br /> v <br /> CA �! ' 3 7 <br /> TI/ BOX O CORPORATION l�INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> It Amer d UST Is apublic aeenq,mnplele the loeowine:name d Supervisor of dMbbn,sectbn,m office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2DISTRIBUTOR 0 / IF INDIAN 1 <br /> RESERVATION %OF TANKS AT SITE E.P.A. I.D.%(gNimaq <br /> 0 3 FARM 4 PROCESSOR OTHER ORTRUSTLANDS ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME AST,FIRST) PHONE%WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> 4__11 — <br /> (LAo 3 <br /> NIGHTS: NAMEST.FIRST) ONE%WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SIJ �!✓ <br /> MAILING OR STREET ADDRESS .O Z ✓ bol b IMbab INOIYIDUAL 0LOCAL-AGENCY 0STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> ITV NAME STATE ZIPCC�ODE pp PHONE%WIT�HjAREA CODE /2 <br /> ly <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREET ADDRESS ✓ bocWndbats 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION 0PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> Ii DG E Z:�,2 ;7f- <br /> IV. <br /> ZIV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-1-lJ� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bubiMkNe 0 1 SELF INSURED O 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTEROFCREOIT =6 EXEMPTION 0 911 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: L II. 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 NAM E(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYMEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDK)TION It FACILITY% <br /> LOCATION CODE -OP77ONAL CE��S TACT% -OPTIONAL 9UPV �-DISTRICT CODE -OPTIONAL <br /> THIS FOAM MUST BE ACCOMPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IWORJATION 0!1 . <br /> OWNER MUST FILETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) <br /> FOi0a17AA7 <br />