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�... <br /> STATE OF CALIPoRMA o <br /> STATE WATER RESOURCES CONTROL BOARD ;ng <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrrY1SITE <br /> MARK ONLY O NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION �7 PERMANENTLY CLOSED SITE V <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT F 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA O/R�FACILI NAME NAMEOF OPERATOR <br /> PARCEL"(OPTIONW l <br /> ADDRESS NEAREST CROSS STREfii _ Iq _21� <br /> CITY NAME STATE ZIP CODE 91 PHONE a WITH AREA CODE <br /> CA >n <br /> T 11Box <br /> TE 0 CORPORATION 0 INDIVIDUAL ARTNERSHP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERALAGENCY' <br /> DISTRICTS' <br /> N 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 1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.D.a(CP m") <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS L <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST ST) PHO •WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 2� <br /> 1,1NAMELASL FIRS PHONE a WITH AREA CODE NK TS:NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> 1 : <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING( 'OVB STREET ADDRESS ✓ bmtIndkin I� INDIVIDUAL 0 LOCALAGENCV Q STATE AGENCY <br /> N L O CORPORATION ARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME STS PHON WITHCODEP �DFM ,3- <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OOWNER ID CARE OF ADDRESS INFORMATION <br /> �- <br /> MAILING OR STREET ADDRESS v bexblMbrte O INDIVIDUAL 0 LDCAL-AGENCY 0 STATE AGENCY <br /> szj <br /> CORPORATION 0 PARTNERSHIP O COUNTYAGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> I y 073 -(oN <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 /> ✓ Eox binEkm 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O A SURETY BOND <br /> 1715 LETTEROFCREDIT O 6 EXEMPTION O W 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.E:] it.5e�— III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY If JURISDICTION AI FACILITY i <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL 9UPVISOR-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 /> FORMA(393) FOR00]fAe1 <br />