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-4a - <br /> +�-�/' STATE OF CALIFORNIA .� - i <br /> STATE WATER RESOURCES CONTROL BOARD ;m� - o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :- , , a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE Cit ROeM'w <br /> MARK ONLY O f NEW PERMIT 0 3 RENEWAL PERMIT I] 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT E::] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F�CILITY NAME .(/.', NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTIONAL) <br /> Z/6 ';ice ne <br /> CITY ryAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> To <br /> le ATE 0 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY'DISTRICTS' <br /> If comer of UST is a public agency,complete the following:name of Supemisor of division,section,or Office Which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORRESEF INDDION N OF TANKS AT SITE E.P.A. I.D.N fopllorrel) <br /> 0 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicaleINDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ED CORPORATION O PARTNERSHIP COUNTYAGENCY D FEDERALAGEWY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> /_ C-..2 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ fnsbindicate EYINDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> ! LA f I'" 'ZG/� O CORPORATION O PARTNERSHIP E-1 COUNTY-AGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE TPHONEX WITH AREA CODE <br /> 0 7 -4 7-7- <br /> IV. <br /> -7IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa b Indicate 0 1 SELF-INSURED (]2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 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 II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.[-L?' 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) OWNERS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SrTE INFORMATION ONLY. <br /> FORMA(3 J3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR0037AR7 <br />