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• � � � t6Ou-CC O <br /> 9 <br /> STATE OF CALIFORNIA W* """ c <br /> STATE WATER RESOURCES CONTROL BOARD p <br /> UNDERGROUND STORAGE�TANK'P�RMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE I� <br /> MARK ONLY 1 NEW PERMIT 7] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO D.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I, FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) f <br /> DBA OR FACILITY NAME ` g - ! NAME OF OPERATOR <br /> r <br /> AD RFSS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> sp, Z2 <br /> CI AME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX ORPORATION. Q INDIVIAML Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY•AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agency,complete the fallowing name of supervisord dwiWn,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTORQ ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR �� OTHER OR TRUST,LANpS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIG 7S:- AME[LAST,FIRST) PHONE#WITH AREA COO NIGHTS: NAME{LAST,FIRST) PHONE#WITH AREA CODE <br /> 14 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STR ET AD R S ✓ box to indxa e Q IN IVIDUAL C7 LOCAL-AGENCY Q STATE-AGENCY <br /> RPORATION Q PARTNERSHIP Q COUNTY-AGENCY © FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 44 5z6-z- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS T ✓ boxtoindical <br /> Q WOIVI➢UAL OCAL-AGENCY Q STATE-AGENCY <br /> APA, Zib CZ�86RPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAK4E w+ STATE ZIP CODE PHONE#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 DUST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hoxloindicate ;+-' 1ELF-INSURED Q 2 GUARANTEE Q 3 WSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION =7 STATE FUND <br /> Q 6 STATE FUND G CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THISFDRM HAS BEEN MWeDbN A fitiEiVAL7 OF P�RJUU RVPD THE BEST OF MY KNOWLEDGE,1S TRUE AND COl4R�T <br /> r f I <br /> TANKiOWNER'g�NNME'(PRIiVTEIIY f§IGNATURE) F C TANK OWNER'S TITLE DrE G ONNTItroAYNE)R <br /> /29-;> (ALJ / <br /> LOCAL AGENCY USE ONLY 17 _•,s <br /> COUNTY N JURISDICTION If FACILITY# /. - <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 /> FORMA($- '^-DOWNER MUST FILE THIS FOR'"TTHE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�STORAGE TANK REGULATIONS <br /> 95} f <br />