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'�boan p <br /> STATE OF CALIFORNIA �+ <br /> STATE WATER RESOURCES CONTROL BOARD s m •. a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION O 7 PERMANENTLYCLOSED <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> ORA OR FACT ITV NPME. NAME OF OPERATOR <br /> ADDRESS A Std- NEAREST CROB$.$ EET PMCELx(OPrgNAIJ <br /> CITY NAME STATE r ZI D SITE PHONE x WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL (]PARTNERSHIP 0 LOCAL-AGENCY O COUNTY AGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> M owner G UST is a public agency.mrtplete the lollowinB:name of Supervisor of division.section.DISTRICTS n,m onice which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR <br /> Q <br /> SITEE.P.A. <br /> SNDIANIO <br /> 3 FARM 4 PROCESSOR RESERVATION <br /> 6 OHER ORTRULANDS I.D.x(npNmalJ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHGNE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME AA JA ^ r P itv Cmh`v CARE OF ADDRESS INFORMATION <br /> MAILI GOR STREET ADDR A { ✓ boM bintlicaN D INDIVIDUAL O LOCA4AGENCY 0 STATEAGENCY <br /> (/U A <br /> S,Lc /L.e. Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERALAGENCY <br /> ( CITY NAME 6STATE � PHONE x WITH AREA CODE <br /> CL- ) CA ZIPC D <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME ( NE CARED DD ES`INFOR ATION <br /> MAILING ORS R ET ESS `'LNI/� ��r ✓box binkm L-1 INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME ST ZIP QPOE �-L P ONE#WITH AREA CODE ^� <br /> J 1 Y <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box 1c Indicate 0 I SELF INSURED LD 2 GUARANTEE =3 INSURANCE <br /> O 5 LETTER OF CREDIT O O B9 OTHER <br /> &EXEMPTION O<SURE Y SONO <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 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE I DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY e b <br /> t <br /> COUNTY# JURISDICTION Y _ <br /> CATION CODEOPTIONALLOCENSUS TRACTIN-OPTIONAL 9l1PVISOR-DISTRICT CODE -OPTADAW. <br /> D <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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORlg331.g7 <br /> 4,� IK,n� »r ; 10 0 <br />