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t STATE OF CALIFOpNIA <br /> * sr <br /> FORM A `s <br />..! STATEWATER RESOURCES CONTROL BOARD I� - <br /> ' pUND STORAGE SANK PERMtif pTY�99LI�ATIO - <br /> R UNDERGR COMPLETE THIS FORM FOR EAC ❑ 7 PERMANENTLY CLOSED SITE <br /> 5 CHANGE OF INFORMATION _ <br /> 1 3 RENEWAL PERMIY 5 . <br /> } NEW PERMIT I� 6 TEMPORARY SITE CLOSURE <br /> MARK ONLY 2 INTERIM PERMIT <br /> p 4 AMENDED PERMIT <� <br /> ONE ITEM 0 MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> 1. FACILITYISITE INFORMATION&ADDRESS-( PARCELk(OPTIONAL) <br /> DBA OR FACILITY NAME <br /> S STREET <br /> SITE PHONE#WITH AREA CODE <br /> PCODE <br /> ADDR 55 � � STATE Z1 <br /> CA G FEOERAL•AGENCY' <br /> CITY NAMFr. r r <br /> CAL-AGENCY [:] OOUNTY'AGENCY' Q STATE AGENCY' 0 <br /> �—C] 4• <br /> INDIVIDUAL � PARTNERSHVF � DISTRICTS <br /> ✓80X CORPORATION #OF TANKS AT SITE F.P.A. I.D.#(©Afronal) <br /> name d sapeNisor 01 division,swion or oilice wh ch opeha4es tha U5T ✓IF INDIAN <br /> TO INDICATE complete thelolVowln9: RESERVATION <br /> q awner al UST is a public agency C] 2 DI`;TRIBUTOR S OTHER OR TRUST LANDS O ijon3l <br /> TYPE OF BUSINESS Q I GAS STATION 4 PROGESSOP (SECONDARY) P <br /> 3 FARM EMERGENCY CONTACT PERSON I P NE#WITH RFA CODE <br /> PRIMARY) DAYS: NAME(LAST,FIRST) Q> + a <br /> Y <br /> EMERGENCY CONTACT PERSON P ONE#WITH AREA CODE E <br /> ' PHONE.#WITH AREA COD <br /> DAYS: NAME(LAST,Fl ST) ' NIGHT41' S: NAME(LAST'FIIRST) <br /> PHONE#WITH REA CODE <br /> NIGHTS'. NAME(LAST,FIRST) <br /> INFORMATION <br /> MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION STATE-AGENCY <br /> Ii. PROPER n OWNER -{ � 0 LOCAL.AGENCY Q FEDERAL-AGENCY <br /> NAME j Y „� i /� ✓ box 1)no Cale INDIVIDUAL COUN .AGENCY fl <br /> rrl r CORPORATION PARTNERSHIP <br /> PHONE#X TH AREA GODS, ��s <br /> Tn ET ADDRESS STATE ZIP CODE ] { J I� <br /> MAILING OR S f cT <br /> CITY NAME <br /> -r MUST BE COMPLETED) <br /> GARS OF ADDRESS INFORMATION STATE-AGENCY <br /> III. TANK OWNER INFORMATION'( r ED LOCAL.AGENCY FEOERAGFNCY' <br /> NAME OF OWNER ✓ pox to indicate a INDMDUAI COUNTY•AGENCY <br /> 0 CORPORATION (]PARTNERSHIP <br /> p}1=111IT11AREACODE <br /> MAILING OR STREET ADDRESS STATE ZIP CODE <br /> CITY NAME 014I 916)322-9669 if questions arise. <br /> EQUALI7-ATION UST STORAGE FEE ACCOUNT NUMBER- <br /> IV.BOARD OF S USED <br /> TY(TK) Ho 4Df�� MUST BE COMPLETED)-IDENTIFY THE METK4D( ) a 7 STATEFUND <br /> LETTER OF CREOIT a B EXEMPTION 99 OTHER <br /> . ------------ <br /> PETROLEUM UST FINANCIAL RESPONSIBILITYNs ONCE lC3 d SURETY BON4 tD LOCAL GOVT.I'ECHANISM <br /> Q 1 SELF-INSURED Q 2 GUARANTEE � 9 STATE FUND&CERTIFICATE OF DEPOSIT <br /> `�box to mdicate � B STATE FUND&CHIEF FINANCIAL OFFICER LETTER 1] <br /> Legal noti4iCation and billing will be sent to the tank owner unless box Ilor ll is cher e <br /> I.[] <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS USED FOR LEGAL NOTIFICATIONS AND aILLING: +s r���AND coR�Fcr <br /> CHECK ONE BOX INDICATING WHIGH A80VE ADORES DATE MONTHiDAYlYE <br /> MPLETED UNDER PENALTY OF PER.IUFIY,AND TO THE BEST OF MY KNOWLE�O <br /> THIS FORM HAS BEEN CO TANK OWNER <br /> S TITLE <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) <br /> LOCAL AGENCY USE ONLY JURISDICTION# D •� <br /> couNTv# ED <br /> SUPVISOR-DISTRICT E�-0PTdONA <br /> E •OPTIOFiAL CENSUS TRACT# -OP l0�L <br /> LOCATIO C ;, '-- UNLESS THIS IS A CHANGE OF SITE INFORM <br /> OR MORE PERMIT APPLlOAT10N• FORM s, TORAGE TANK REGULATIONS <br /> F THE LOCAL AGENCY IMPLEMENTING THE UNDER <br /> THIS FORM MUQWNER MUST ACCOMPANIED <br /> A LEAST(1) <br /> A A(6-95) y� <br />