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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT F—] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION I.3;e7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAM OF OPERATOR <br /> ' - V 1 _ 4- c <br /> ADDRESS Lf _)L.— NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAM STATE '1_j ZIP CODE l SITE PHONE s WITH AREA CODE <br /> it, CA <br /> ✓ BOX CORPORATION (] INDIVIDUAL (]PARTNERSHIP �LOCAL-AGENCY <br /> TO INDICATE 0 DISTRICTS' 000UNTY-AGENCY' (] STATE-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 a 1 GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS SITE E.P.A. I.D.a(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION L'/-�{.C'66 `' 1-:,3� Icy ORTRUST LANDS 6 f i <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA (LAST,FIRST) PHONE#WITH AREA CODE DAYS: N ME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NI HTSAME(LAST,FIHONE ad WITH AREA CODE NIGHTS: AME(LAST,FIR PHONE#WITH AREA CODE <br /> : R r _ <br /> II. PROPERT OWNER INFORMATION• MUST BE COMPLETED <br /> NAME, 9 s CARE OF ADDRESS INFORMATION <br /> S ��/ J ,ev, <br /> M�1 :PL E T ADDRESS ✓ box b indicate = INDIVIDUAL OCAL-AGENCY 0 STATE-AGENCY <br /> ' (]CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> 14 <br /> CITY NAME- STAT5E ZIP CODE PHONE#WITH AREA CODE <br /> Grp <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> - ?'ill <br /> I A MAILING OR STREET ADDRESS ✓ box to indicate— INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ! C° ✓ _ CORPORATION O PARTNERSHIP COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> CITY NA E STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOABP OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate t SELF-INSURED 2 GUARANTEE X31NSURANCE (]4 SURETY BOND <br /> (� 5 LETTER OF CREDIT 6 EXEMPTION O 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 if.0 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 8 SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> (�,ice P <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 FOR'"'J!TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRn""n STORAGE TANK REGULATIONS <br /> FORM A(3(93) FOR0033A R7 <br />