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• see <br /> STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> . . o <br /> COMPLETE THIS FORM FOR EACHFACILRY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT E7] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR ILI N E -� NAME OF OPERATOR <br /> IF ------ <br /> ADORE �a ^O N-----------STREETj)'AOA PMCELI(OPrIONAU <br /> CITY NAMF/7L/j�('(JSTATE ZIP CP3F,-/xV V- - SITE PHONE#WITH AREA CODE <br /> 11 PDXtool <br /> CA 7ZE� <br /> TOINDICATE O CORPORATION O INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY COUNTY AGENCY O STATE-AGENCY' O FEDERAL-AGENCY' <br /> If owner of UST Is a public agency,conplete the following:name of Supervisor of divisbn,section,Dor office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION F-1 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optima/) <br /> 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME( FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box blMbais Ei INDIVIDUAL 0 LOCpL-AGENCY STATE AGENCY <br /> CORPORATION 11 PARTNERSHIP COUNTY-AGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE 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 bimi ale 0 INDIVIDUAL LOCAL AGENCY ED STATE AGENCY <br /> CORPORATION PARTNERSHIP COUNTYAGENCY7] FEDERAL CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 1414- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box lo Indicate I0 1 SELF INSURED Q 2 GUARANTEE El INSURANCE <br /> IED 5 LETTEROFCREDIT O 4 SUREN BOND <br /> 0 6 E%EMPTION l� S9 OTHER <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: LE II.E-] 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'STITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# <br /> LOCATION pQ -OPTIONAL CENSUS TRACT# -OPTIOANj.iA D SUPVISOR-DISTRUTOODE -OPjp <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA dHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS \l <br /> 0 p <br /> 0037AM\_1 <br /> v� <br />