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1 a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT11� 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OfAFq <br /> CITY N7ILITYN E ^ NAMEOFOP RATOR <br /> .— <br /> ADDR SSS `\1 <br /> f NEARESTCR ST ET PARCELI(UF1UNAU <br /> CITY NAM •jJ" `> <br /> STATE ZIP � SITE PH Ea WITHAREA CO <br /> I/ BOX �/ CA (o a_ 6 <br /> TOINDICRTE O CORPORATION LyJ INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY' <br /> /� DSiRICTS' FEDERAL-AGENCY. <br /> If wmer of UST le A public agency,torrylele the following:name of Supervisor of division,aeabn, IS orrice ' operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR O ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.a(optional) <br /> 3 FARM = 4 PROCESSOR5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAVE: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE=AREACODE <br /> c th NIGHT�NAOME1 T,FIRST) PHONEa WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME A CA RE OF ADDRESS INFORMATION <br /> V7 G <br /> MAILING ORS EET ADD ES$ ✓box blndkab LOCAL,L T" NDIVIDUAL E] STATE AGENCY <br /> L CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY Q FEDERALAGENCY ! <br /> CITY AME STATE ZIP CODE PHONES WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C <br /> NAME OF OWNER <br /> -/) CARE OF ADDRESS INFORMATION <br /> MAILING OR SSTREET ADDRESS ✓ boz bindba4 OINDIVIDUAL <br /> LOCAL AGENCY 0 SSTATE-AGENCV <br /> E-1 CORPORATION = PARTNERSHIP E-]COUNTY AGENCY Ell FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 /> ✓ <br /> box b Indicate E-21 SELF-INSURED (]2 GUARANTEE 3 INSURANCE <br /> O 5 LETTEROFCREDIT O 99 OTHER <br /> 6 EXEMPTION O SURETYBOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or�Ilis checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E II.I < III.D <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 TfIIE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION i FACILITY# <br /> NAL <br /> LOCATIONCODE -OP CENSUS TRACTa -OP L 9UPVISOR- TpO(��pyE .OpTp� <br /> f(l1 O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SPIE 1111FORMATION ONLY, <br /> FORM A(3M3) IONS <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 1, <br /> —,RAG, FORDM3AA7 <br />