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a <br /> STATE OFCALIFORWASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AItCOMPLETE THIS FORM FOR EACH FACILTTYISTTE <br /> MARK ONLY O 1 NEW PERMIT ED 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE / <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMEN m S TEMPORARY SITE CLOSURE <br /> 1. FACILM/SITE INFORMATION 14 ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME p1 tN NAME OF OPERATOR <br /> ADDRESSNEAREV OSS STRE PARCEL'(OPTIONAL) <br /> g1puGa <br /> C NAME (� D / i 9 TE ZIP CODE SITE PHONE a W ITH AREA CODE <br /> ca D <br /> ✓ Box f�CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTYAGENCY' O STATEAGENCY' D FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> •N mm,of UST Is a public agency.mWisto the tolowing:narm W SMPenhcr of division,section,or oaks which operates the UST - <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE I E.P.A. I.D.is(gNlanel) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTA PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> NEDAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> 04'S: (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- ST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MNLING OR STREET ADDRESS ✓ bmsamicae 0INDIVIDUAL LOCAL-AGENCY f� STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP ED COUNTY-AGENCY O FEDERAL AGE NCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLE D) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boablMlals INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME TATE ZIP CODE PHONE#WITH AREA CODE <br /> BOARD OF EQUALIZATION UST STORA E ACCOUNT NUMBER-Call(916)'9f?E�5669if questions arise. ' _ <br /> t Y_MHO F4141- - d a t act f4`/ HQ36 -62 7 <br /> �erlsKere f* 1 '13- 93 ' --0037 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Dor birdbate 1 SELF-INSURED (]2 GUARANTEE O 3 INSURANCE O a SURETY BOND <br /> 5 IETTEROFCREDIT S EXEMPTION C-1 99 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.Q II.O In.0 <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 a SIGNED) OWNER'S TITLE DATE MONTFVDAYNEAR <br /> is -/3 - -5- <br /> LOCAL AGENCY USE ONLY ©jEG 1( Zqo <br /> COUNTY�a JURISDICTION# FACILITY# <br /> i -'-/—' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL. <br /> Z ZZ J <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR TION NL . <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR3a13ANT <br />