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STATEOFCAUFORIA -ace�F e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A a <br /> ;�� as <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �° a� <br /> C�IiIOFM�- <br /> MARK ONLY ❑ � NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE REM '0 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ C AMENDED PERMIT <br /> ❑`e TEMPORARY SITE CLOSURE --- <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA O11 R FACILITY NAME ^ <br /> NAME OF OPERATOR u <br /> ADORES <br /> 7 NEAREST; O STIiE Ela(OPrgNAy <br /> CITY NAME <br /> STATE ZIP CODE <br /> `A 917E PHONE#Will p DE <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY <br /> N owner d UST is a Public agency,00mPlete thefollowing:name o/Supervkor o/division,section.or oHlbe which aCe LIST AGENCY' Q pTE.AGENC OFEDERAL#GENCY- <br /> TYPE OF BUSINESSaperetea the UST <br /> ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS pi SITE E.p,A. I D a(geNanaQ <br /> ❑ 3 FARM ❑ 6 PROCESSOR 5 OTHER ❑ RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAS FIRST) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE a WITH AREA CODE <br /> GAYS: NAME(LAST,FIRST) PHONEa WITH gREA CODE <br /> NIGHT : N M (LAST,FI T) NEa _ <br /> H R DE NIGHTS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR§T EE ADDR <br /> ✓ boxbMdkaro =3 INDIVIDUAL 0 LOCALAGENCY STATE-ACENCY <br /> CITU NAME - — CORPORATIONPARTNERSHIP 0 COUMYiGENCY <br /> STATE 21P CODE O FEDEML-AGENCY <br /> _ - 'L/ / PHONEa WITH AREq CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) C <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> s ✓ box bintlkaU (] INDIVIDUAL 0 LOCAL-AGENCY <br /> CITU NAME Con RATION I--] PARTNERSHIP 0STATE-AGENCY <br /> STATE �fAUMVAGENCY � FEDEML.pGENCY <br /> ZIP CODE PHONE a WITH AREA CODE <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 /> ✓Wa blMkale (] I SELF-INSURED <br /> 0 5 LETTER OF CREDIT 0 2 GUARANTEE O 7 INSURANCE <br /> (]6 EXEMPTION 0 N OTNER Q<SURETY SONO <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: <br /> I, 11.❑ 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 8 SIGNED) <br /> OWNERS TITLE <br /> DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> st — <br /> COUNI # JURISDICTION <br /> FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -CPTg7NAL FED <br /> �; 9UPVISOR-pISTRICT CODE •GPnONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLNCATIOH• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOgBD)6AN7 <br /> • .� Iy 111 /z <br /> 5-13'_ 7111°. 10?, <br />