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STATE OF CALIFORNIA • Exna""<e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .� - e`id <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF ILITY NAME NAME OF OPERATOR <br /> ADDRES NEAREST CROSS STR PARCEL#(OPTIONAL) <br /> 2� t K d . <br /> C 7)GrJ tL STA`T,EA ZIP CODE ITE PHONE#WITH AREA CODE <br /> ✓BoxCORPORATION 0 INDIVIDUAL O PARTNERSHIP �LOCAL-AGENCY OCOUNTY-AGENCY' O STATE'AGFNCY' <br /> TO INDICATE ( DISTRICTS O FERA <br /> DEL-AGENCY' <br /> #ownerd USTBubIC ap99811LY,ampkle the folbwng risme dsuperhsurd dKaun,seUipP or office whXJl opereNe the UST <br /> TYPE OF BUSINESS IGl i GAS STATION ❑ 2 DISTRIBUTOR O VI <br /> IRF ITIONNDIAN #OF TANKS AT SITE E.P.A. I.D.#(Optional) <br /> VA <br /> RESE <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ f OTHER OR TRUST(ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E( T,FIRST) `( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> QS I(V' <br /> NIGHTS: NAME(LAST,FI T) PHONE4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> N E I J t" (h S CARE OF ADDRESS INFORMATION <br /> MAILINGORS EETADDR S ✓ box to idwle I1 INDMDUAL 1:3 LOCAL-AGENCY $TATE-AGFNCY <br /> ?I 2� [CORPORATION O PARTNERSHIP Q COUNTY-AGENCY tp FEDERA-AGENCY <br /> CI E STA, ZIP—IS Z I AR COD�W <br /> n l/J/�C 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N OF l lcI VAS CARE OF ADDRESS INFORMATION <br /> MAILING INOR Sii/7ETAD RESS ✓ boxtokmimte Q INDIVIDUAL =LOCAL-AGENCY O STATE-AGENCY <br /> 1 V( J I�CORPORATION ED PARTNERSHIP = COUNTY-AGENCY O FEDERAL-AGENCY <br /> �70Y�/! l v '' ST ZIP • P ONE�N(TbLq_f1� ODE�1 <br /> IV. BOARD OF EQUALIZ�Ay�TI�ON�UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY <br /> J\((#(7y <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box tolMkale I= 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE Q 4 SURETY BOND Q 5 LETrEROFCREDR Q#EXEMPTION 0 7 STATE FUND <br /> O 8 STATE FUND A CHIEF FINANCIAL OFFICER LETTER (#STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 99 OTHER <br /> - <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: I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMP ED UN ER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TA NAME PRINTED IGN E) T KOWNE 'S DATE M0 THIDAY EAR <br /> k� ' L IQ TT e- (z � r <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> r�-/--I <br /> LOCATION CODNAL CENSUS TRACT# -OP ONAL SUPVISOR-DjSTRICT CODE •OPTIONAL <br /> ©C!/1 i <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 /> FORM A(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUITORAGE TANK REGULATIONS <br /> 5-i3 - yid <br />