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tb UA G' <br /> STATE OF CALIFORNIA .� <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> SvS� Cac or-0:ov\ l C-rd Cka(�,fs Lc_u6r'/ <br /> ADDRESS NEARES C O STREET PARCEL#(OPTIONAL) <br /> �i3L vC' fj <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> .1 CA 9 5 Zc5 <br /> ✓ Box 77 CORPORATION INDIVIDUAL = PARTNERSHIP AL-AGENCY <br /> TO INDICATE DISTRICTS' (] COUNTY-AGENCY' [] STATE-AGENCY' FEDERAL-AGENCY' <br /> It owner of UST is a public agency,complete the following:name of Supervisor o1 division,section,or oHioe which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR 0 RESERVATION FINDAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAY 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 /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S _ <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY ] STATE-AGENCY <br /> (]CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE rODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADD ES INFORMATIO <br /> SL 4 G� r U C C.C5 <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 'n( CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME �1 � STATE� ZIP CODE � P?©#WITH AREA CODE�O� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box lo indicate L� I SELF-INSURED 2 GUARANTEE n 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION ] 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.[—] II.[�] 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> �A 7 <br /> LOCATION CODE -OPTIONALCENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> b � Z ` Z3 , —9—�--; <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT 4PPI ICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. f� <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKNIS <br /> FORM A(3(93) FOI 7 \� <br />