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• STATE OFCAUFORTUA • "``' <br /> STATE WATER RESOURCES CONTROL BOARD �" <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A '�`� a <br /> 77 COMPLETE THIS FORM FOR EACH FACILITY/SITE �,� <br /> <i10„M.n <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE ITEM ❑ 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CL <br /> 2 INTERIM PERMIT O _ <br /> ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB R FACIL�NAM L <br /> f C <br /> NAME SOF OPERATOR <br /> ADDflES9 /7 Q N Com-- <br /> N REST CgO353TgEETL '�.�pp PpgCEU(OPrgNAq <br /> CITY NAM �a.n <br /> STATE zilP O 3 PHO* i WITH AREA CODE <br /> ✓Box CA s ao q TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY <br /> DISTRICTS• 0 COUNTYAGENCY' STATE-AGENCY• 0 FEDEML-AGENCY' <br /> If owner of UST Is a public agency,Corrplete the following:Darns n SUPON60r of division,senion,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN NOF 7ANKS AT SITE E.P.A. I.D.*(rWiarsp <br /> 3 FARM 4 PROCESSOfl 0 5 OTHEfl ORTRUS7 LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> WjE <br /> PH NEi WITH AgEA CQDE/ DAYSNAME(LASFIRSTPHONE i WITHAREACODE <br /> C� NEN WITH AREA DaD NIGHTS: NAME(LAST,FIRST <br /> PHONE*WITH AREA COOS <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDR <br /> ✓hox b npoRATs �INDIVIWAL l� LOCALdGENCY �STATE-AGENCY <br /> CITY NAME V Cl ,(, , l�CARPoRATION 0 PARTNERSHIP �COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> G' ^rJ'� ST E 21P CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �3 /� a <br /> ECITYNAME <br /> R <br /> S' � J CARE OF ADDRESS INFORMATION <br /> EET ADDRESS a/ <br /> ✓box bindicale INDIVIDUAL 0LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> O CORPORATION PARTNERSHIP0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> STATE 21P CODE PHONE N WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hox <br /> Is Indicate 0 I SELF-INSURED 11 2 GUARANTEE PT1ON X OS <br /> .( INSUgANCE^, <br /> D 5 LEREfl OFCREDT 0 e ExEM99 OTHER tel/ ( L4 <br /> POREjYPOND <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 A1Y KNOWLEDGE,IS TRUE D CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) <br /> OWNER'S TRLE DATE MONTWDAYrVEAfl <br /> LOCAL AGENCY USE ONLY <br /> Rec // ] / <br /> COUNTY N JURISDICTION N <br /> l F�ACILffY7f <br /> E�N,11111111OP�770NI AL/I CENSUS TRACT* -OPTIONAL <br /> 9UPVISOR-OT��OODE -1:1111,7p111111AL <br /> 3, �a <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(M) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • * FOHDOJ34R7 <br />