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• • Awa• e <br /> STATE OF CALIFORNIA :� <br /> STATE WATER RESOURCES CONTROL BOARD ;o v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ,s <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ° caM` <br /> MARK ONLY O I NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E] 7 PERMANENCLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 1 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF ILITY NAME - NAME OF OPERATOR <br /> SIVA, OVA Loo , <br /> ADDRESS NEARS TCROSS STREET PARCEL#(OPTIONAU <br /> z/6 yv4z n <br /> CITY NAME . STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> T/-K-NJ_BOX O CORPORATION INDIVIDUAL 0 PARTNERSHIP � DSTN- BENCY O cousr"AGENCY' O STATE.AGENCY' 0 FFDEMLAGENCY- <br /> N owner of UST Is a publicagency,complete the following:name W Supervisor of CNkbn,section,or ofim which operates the UST <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR / O <br /> RESERVATION <br /> IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM Q / PROCESSOR ,L J(5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAY/g: NN MSE(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAM (LA T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A 77-6 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> ,t,V <br /> MAILING OR STREET ADDRESS I ✓box bindkata EeILDIIAL O LOCAL-AGENCY D STATE-AGENCY <br /> 'L t,(— 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME aTATEZIP CODE PHONE#WITH AREA COD//E <br /> (✓p ,S — b <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME QF OWNEA CARE OF ADDRESS INFORMATION <br /> MAILINO�OR SNTREET ADDRESS ✓ box bintlkak Elr6IDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> o O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NA STATE ZIP CODE PHONE#WITH AREA CODE <br /> �z o -6 Z-9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate O I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE D I SURETY BOND <br /> O 5 LETrEROFCREDIT O B EXEMPTION O 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: 1.0 II.EPK 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 B SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® oho <br /> LOCATION CODE;Z:��AIAL ACT# <br /> CENSU!3 -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 SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3A3) � . FOR0033Afl7 <br />