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' STATE OFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACHFACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT <br /> j�? <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ ;A&fi CHANGE OF INFORMATION 7 PERMANENTLY CLgSEp-gL , <br /> LD 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACIL NAME (,[E / �7 <br /> AMEO <br /> ADDRESS <br /> N CF// ROA/ fl a C) All <br /> ) I C�i NFOIRES TCC SS S�RE PMCELi(OPfgNgU <br /> J `C <br /> CITY NAM <br /> �. STATE ZIP S PHO NE i WITH AREA CODE <br /> ✓Box Ca i h5 ao � l7- <br /> TOINDICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL#GENCY <br /> 'N owner al UST Ie a public apenty,Wrrpl9le the/ollowing:name o/SUPOINeor of diveli waIbnDISTRor ce wrybh 0 AUNTY-AGENCY• 0 STATE AGENCY• 0 FEDERAL#GENCy <br /> TYPE OF BUSINESS O O operates the UST <br /> 3 FARM <br /> STATION 2 DISTRIBUTOR ❑ RESERVATDION i TANKS AT SITE E.P.A. I.D.i(optimal) <br /> ❑ [� 4 PROCESSOR Q 5 OTHER OR TRUST lAN03 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PH NEi WITH AREAC DE <br /> All 11 N/ �® �� � DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAM (LA$T,FIRST), C.YR NEe WITHAREA <br /> L / NIGHTS: NAME(LAST.FIRST) <br /> PHONE i WITH AREA CODE <br /> t � <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME <br /> ( I _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ <br /> CORto.PORATION <br /> �INDIYIDUgL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME Ac- <br /> r sO CORPORATION D PARTNERSHIP O COUNTY#GENCY 0 FEDERAL-AGENCY <br /> (/ c ZIP CODE PHONE A WITH AREA CODE <br /> 30 <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED) (OJ <br /> ENAMEOFOWNERINFORMATION <br /> R STREETNDIVIDUAL EILOCALAGDICYO PAgTNERSMP O STATE-AGENCY <br /> 000RPORATION D COUNrY#GENCY 0 FEDERAL AGENCY <br /> STATE ZIP CODE H AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)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 /> ✓bmbiMbara 01 SELF-INSURED 0 2 GUARANTEE 0-S INSURANCE <br /> O 5 LETTER OF CREPT I�S E%EMP ION _ 0 A SURETY BONG <br /> 99 OTHER (1 ofil - <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.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND 60IRRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) <br /> OWNER'S TITLE LDATE: I , JTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> IFC <br /> COUNTY p /17 !JURISDICTION N <br /> FACILITY 1r <br /> LOCATION CODE -OPTIONAL CENSUS TRIll:Ti .1:11TiOAAL <br /> n . - 9UPVIBOR- Ill 7RICT CODE -OPl'AOALAL <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(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> g l'l- ct 4�oj It),l- �� gra MDabpy <br />