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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD r <br /> j � r <br /> UNDERGROUND STORAGE TANK KRIT APPLICATION- FORM A <br /> COMPLETE THIS FORMF R iAC PILITYISITE <br /> MARK ONLY F7 t NEW PERMIT 3 RENEWAL PERMIT5 ANGE OF INFORMATION 7 PERMANENTLY CLO§EDSq E <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> r1z 1� E-1 26h C,\ <br /> ADDRESS I �} NEAREST CROSS STREET PARCELO(OPrIONAL) <br /> CITY NAME �f STATEZIP C DE SITE PHONE#WITH AREA CODE <br /> CA . <br /> V BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION [] 2 DISTRIBUTOR 0 ✓ IF INDIAN 14P OF TANKS AT SITE E.P.A. I.D.#ppfiana)l <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR O 5 OTHER 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(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indkine INDIVIDUAL LOCAL-AGENCY © STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NA"INFORMATION,/(� <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TATION-(MUST BE COMPLETED) <br /> NAME Oyort1 M� CARE OF ADDRESS INFORMAT h� � � <br /> rl & 61115 <br /> fz"i <br /> MAILING V / �[ ✓fG�balb`Fi/nd eats INDIVIDUAL LOCAL-AGENCY(, STATE-AGENCY <br /> t (moi l�N .A ;4 D CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Lj FEDERAL-AGENCYCITY NAW� wjLAf 6 �� STATS ZIP�Crpp� y� PHONE#WITH AREA CODE <br /> IV.BO iTIIQLUALIZATIOON 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 B METIiOD(S} USED <br /> ✓ box to II 0 I SELF-INSURED [�:)2 GUARANTEE (] 3 INSURANCE 0 e SURETY BOND <br /> E7 5 LETTER OF CREDIT 0 6 EXEMPTION 7] 99 OTHER— <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification illing will be sent to thef tank owner unles x or 11 is c e <br /> F <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NO ICATIO AN ILLINP �A.. I� Q II.❑ III, <br /> 4 <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,A THE BES 444111...iiL�i E,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED} OWNER'S TITLE DATE MONTWDAYIYEAfl <br /> LOCAL AGENCY USE ONLY / <br /> �J COUNTY# JURISDICTION# FACILITY# <br /> Ci 1 ► C <br /> LOCATK)N CODE -OPTIOL JCENSUS TRACY/ jrgAL SUPVISOR-DISTRICT CODE -OPT)ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3143) 0 31--3qq <br /> FOR0MMA7 <br />