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' Sim <br /> �d ;• ; <br /> 5TATE Of CAUFORNlA <br /> STATE WATER RESOURCES CONTROL BOARD ate' <br /> ,b a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE._. - <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0 FACIL TY NAME N E pF OPERATOR J <br /> ADDRESS NEAREST CROSS STREET PARCEL K(OPTIONAU <br /> El , - <br /> CITY NAME r STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> `/ BOX LOCAL-AGENCY <br /> TO INDICATE CORPORATION INDIVIDUAL l�PARTNERSHIP 0 DISTRICTS' COUNTY-AGENCYSTATE•AGENCY' FEDERAL-AGENCY' <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 0 2 DISTRIBUTOR a ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.s(optional) <br /> RESERVATION <br /> 3 FARM u 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( Ty FIRST) PHON s W TH AREA CODE DAYS: NAME(LAST,FIRST) PHONE rt WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE x WITH AREA OD NIGHTS: NAME(LAST,FIRST) PHONE r WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS, ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> r-,)/ 1�1 CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME L STATE ZIP CODE PHONE•WITH AREA CODE <br /> "N 9 467 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFh OWNER, CARE OF ADDRESS INFORMATION <br /> 0 <br /> MAILING OR STREET ADDRESS ✓ box toinaicata 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> / I t 0 CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> to s7s .4 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - "`'' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE = 9 INSURANCE 07 = 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER -4-A TF F u YI D <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. I.� III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST GIF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1F JURISDICTION# FACILn_Y it, „f r <br /> LOCATION CODE -OPTIONAL CENSUS TRACT► •OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL t <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) �- -,� FF•JR0607A-R7 <br />