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• sWe <br /> n <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W m� :S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A a <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `"'^°""�� <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ( )i <br /> ADDRESSr NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Atvtw 4r.c4 CA oa 36I- 5 / <br /> T / BoxINDICATE =1 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUMWAGENCY' [=1 STATE AGENCY• O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •H owner of UST Is a public agency,complete the following:name of Supervisor ol d"ion,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTflIBUTOR ❑ RESERVATION/ IF INDIAN »OF TAN AT SITE E.P.A. I.D.#lopaonall <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS 1 <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#620 AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> , or <br /> MAILING OR STREET ADDRESS ✓ box lo Indicate E__j INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTY AGENCY 0 FEDERAL AGENCY <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 /> 5.4 r. As <br /> MAILING OR STREET ADDRESS ✓ W.b indices INDIVIDUAL LOCAL AGENCY =1 STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY AGENCY E:1 FEDERAL-AGENCY <br /> CITY 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 4 4- - 0 Z/ 9 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicas I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION W 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: I. it.❑ 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 NAM E(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® D O O - 8 -S� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> 6D <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLJCATKIN- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. J <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS (� <br /> FORM A(3193) ® FORD033AA-R <br /> ( <br />