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t • <br /> 4�'6pvn �e <br /> 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 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ,FS PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT ffS TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME11 NAME OF OPERATOR <br /> ADDRESS S NEAREST CROSS STREET PARCEL#(OPrIONAL)C.— L 1 TGV.- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> SACK� CA S" 4-04 NOW-W <br /> I/ BOX <br /> TO INDICATE O CORPORATION E::]INDIVIDUAL PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' Q 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 17 n L •1 i t�,...n..,. 1'1 EES{'tic,r'H,6.K <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT7F7 I.D.#(optional) <br /> RESERVATION q <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST DADS <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 /> © '7 CGS b '-- <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �/ �D r(� ✓ box to Indicate = INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> r•I J(S 011A*MRATION = PARTNERSHIP BOUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE <br /> � ZIP CODE PHONE#WITH�ARREA/^C�ODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ` CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Lo, ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY ED STATE-AGENCY <br /> (ter Wig— <br /> CORPORATION (] PARTNERSHIP [�]'G UNTY-AGENCY = 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- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box ID Indicate O 1 SELF-INSURED 0 2 GUARANTEE Ca-TMSURANCE (]4 SURETY BOND <br /> E::)5 LETTER OF CREDIT I]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.O II.[k' 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 TIT DATE M NTWDAY/YEAR <br /> 543 � <br /> LOCAL AGENCY LI§E ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m FTT-1 I I I I I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 /> FORMA(3/93) <br /> OWNER MUST FILE THIS FORTWITH_ THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJrRAGE TANK REGULATM <br /> FOR0033A-R7 <br />