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• • rG60Ve <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W�ffi " ,;8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �""°e"'�. <br /> MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM E 2 INTERIM PERMIT 0 e AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE J <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PMCEL#(OPTONAy <br /> TY N STATE ZIP CODE S TE PH E#WITH AREA CODE <br /> CA <br /> CI!�// <br /> ✓ BOXCORPORATION INDIVIDUAL I� PARTNERSHIP LOCAL'AGENCY O COUNTYAGENCY' STATE-AGENCY' I� FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS' <br /> N owner d UST is a public agency.complete the following:nave of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 ( GAS STATION = 2 DISTRIBUTOR q,/ IFINDIAN <br /> SERVATTION #OF T i KS AT SITE E.P.A. I.D.#(aplianalJ <br /> 3 FARM E_:] a PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#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 /> / /Y of GcrJSa O <br /> MAILING OR STREET ADDRESS �,�/ ✓ bottlirdkale l 1 INDIVIDUAL D LOCAL-AGENCYD FEDERSTATE AL-AGENCY <br /> /� S /O �TDr //r<--G-G O CORPORATION = PARTNERSHIP O COUNrV-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �. 95Z4/v �333-6�8 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /r of /° AQ�t�f�TioR /I�s°r <br /> MAILING OR ST ET ADDRESS ✓ wb indicate = INDIVIDUAL LOCAL AGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAMEST ZIP CODE PHONE#IVITH AREA CODE <br /> Z?-ag�, <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bot tlindicate 0 1 SELF INSURED E-D 2 GUARANTEE S INSURANCE 0 A SURETY BOND <br /> 5 LETTER OF CREDIT =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.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'SNAME(PRINTEDA SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTQN# FACILrTY# <br /> `-' 4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL S;;V OR-DISTRICT CODE -OPTIONAL <br /> v Z ZJ <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 Faa333Am <br /> FORM A(310.3) 0 <br /> 0 <br />