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i • <br /> STATE OF CAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD W ate. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION a 7 PERMANEN SED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD — NEAREST CROSS ST ET PARCEL#(OPTIONAL) <br /> .4- _7" t!> ;f, <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX CORPORATION INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' (]STATE-AGENCY' FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS' <br /> If owner of UST Is a public agency, mplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opflonal) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 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 /> Z S <br /> NIGHTS: NAME(L T.FIT) PHONr=#WITH AREA CODE �2 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL E�:] LOCAL-AGENCY STATE-AGENCY <br /> Z 6fz a- 01 O CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK 0 NER INFORMATION-(MUST BE COMPLETED) <br /> N OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL LOCAL-AGENCY E:]STATE-AGENCY <br /> — .I CORPORATION E=1 PARTNERSHIP (]COUNTY-AGENCY = FEDERAL-AGENCY <br /> CIS ST TE ZIP ODE IPHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIA PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHO (S) USED <br /> 7ZD�1,dt,✓boxbindiwte I SELF-INSURED 2 GUARANTEE 3 URANCE =4 SURE BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION as OTHER t=-lit <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: 1. It. 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® F3T2-W loloIllilf�� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <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 REGULATIO14 <br /> FORMA(3/93) 0 `/�� �� FOR0033A•R7 <br /> l� <br />