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STATEOFCAUFORNIA • .� <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :� a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 t NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT Ej] e TEMPORARY SITE CLOSURE 50 <br /> 1, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME -- NAME OF OPEP�ITOR <br /> /V/ Z) <br /> ADDRESS NEAREST CROSS TREET PARCEL#(OPTIONAL) <br /> CITY NAME /, STAT`# ZIP CODE917E PHONE#WITH AREA CODE <br /> TOIN Box I�CORPORATION i� INDIVIDUAL ED PARTNERSHIP O LOCAL-AGENCY COUNrY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DETRICTS' <br /> If owner of UST Is a public agency,conplate the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR RESEIF RVADDIAN #OF TANKS SITE E.P.A. I.D.SWIanag <br /> 3 FARM 0 4 PROCESSOR GTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 4~A ro <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -- —422—6- <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa blodbate INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> r4 CORPORATION 0 PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY ME STATE ZI <br /> NAP CODE PHONE#WITH AREA CODE <br /> DA 2 v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMOWN R CARE OF ADDRESS INFORMATION <br /> LDI.v <br /> MAILING b <br /> G OR STREET�ADD�RESS ✓ box indicae INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> /GJ1.7-> /(/ I�CORPORATION PARTNERSHIP 0 COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME^ STATS ZIP CODE PHONE#WITH AREA CODE <br /> /,C>0 �Ai4V <br /> IV.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 lrAbxte l�1 SELF-INSURED =2 GUARANTEE a 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER CF CREDIT O 5 MMP ION 0 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L E] 1.[--1 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) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# - <br /> 30an <br /> 6 <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 L4 A CHANGE OF SITE 1F1^tUknDN ONLY.�/ <br /> FORMA(353) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 ! FORda3 A7 <br />