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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE C44TCR"5� <br /> MARK JNLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE _ <br /> ONE ITEM u 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. 'FACILITY1SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBACIR FACILITY NAME r' <br /> NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> 61 <br /> CITY NAME 6� STATE ZIP CO9ri SITE PHONE#WITH AREA CODE <br /> i <br /> V Box <br /> TO DISTRICTS*INDICATE 0 CORPORATION C]INDIVIDUAL C]PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE AGENCY' FEDERAL-AGENCY' <br /> II owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR = / IF INDIAN #OF TANKS AT SITE I E.P.A. 1.0.#(optional) <br /> RESERVATION l <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) r/_ HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ( , <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ) ✓ box b Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> . J —7��./ I �� []CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 1 l 1 STATE- ZIP CODE _ PHONE p WITH AREA CODE <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> l A <br /> MAILING OR STREET ADORES ✓ box io indicale 0 INDIVIDUAL [] LOCAL-AGENCY 0 STATE-AGENCY <br /> /{ jj/r /c / i Y� Q CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME �} STATE ryry ZIP CODE Z PHONE#WITH AREA CODE / <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 F- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate l� 1 SELF-INSURED f--�2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> I� 5 LETTLROFCREDIT F--j 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II. III. <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTFVDAYlYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST 9E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3V93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATMS <br /> • FtTR0033A-197 <br />