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• Gam' • C <br /> # • STATEOFCAUPORMA <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> 1\ UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITWSITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY AME / NAMEOFOPERATOR <br /> ADDRES -/I— �•.� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> r. J <br /> CITY NAME / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Cri-CxlaY•✓, CA <br /> TO a RTE �CORPORATION INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' [=3 STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N adner d UST Is a public agency,CCnplele the foAowing:narne of Supervisor of division,section,or onice which operates the UST <br /> TYPE OF BUSINESS ❑ ( GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIAN <br /> is OF TANKS AT SITE E.P.A. I.D.a(apNmalJ <br /> 0 ON <br /> 3 FARM 0 4 PROCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME `VI CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ADDRESS ^^�� ✓ box bindkate (] INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> t �� O� =CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NME f / �TE�Y IIP7, PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bin#bale 0 INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <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 /> ✓box It Indicate t SELF-INSURED 2 GUARANTEE 6 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION O W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box II or 11 i>s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L ElII.M 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 DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> X <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVNTOR•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 /> FORM A W" OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033Aa <br /> � - <br /> 's,t� d&ea bed � Qt r ' <br />