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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE C4c„p�lM' (I <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> � 0 0 0 <br /> ONE rreh 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR t TY < /�_72— NAME RAT <br /> ADDR SS NEARES STREET PARCEL PTIONAL) <br /> yit,m <br /> CITY NAME ' STATE coD SITE PHONE#WITH AREA CODE <br /> CA <br /> Box <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY <br /> DISTRICTS' <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 0 1 GAS STATION = 2 DISTRIBUTOR0 ✓ IF INDIAN #OFT SAT SITE E.P.A. I.D.#(aWtional) <br /> IF <br /> 0 3 FARM 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 /> 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 /> v <br /> MAILING OR STREET ADDRESS ✓ box IDindicate 0 INDIVIDUAL F-1 LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 7CODE ___[PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -101 <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box%D indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION Q 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: 1.F_j 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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> U <br /> LOCATION COD TIONAL CENSUS TRACT# -OPTIONA f (� SUPVISOR-DISTRICT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Oty. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA �'(�Cl <br /> FORM A(3(93) '` \ 1� FOR0003A-R7 <br />