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STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , <br /> COMPLETE THIS FORM FOR EACH=FACILITY/SITE C4LIP0 NI <br /> sa' :r' <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PER TAY OSE ITE <br /> ONE ITEMX 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE G <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIUrft. <br /> NAME OF OR.QRATOR <br /> ADDRESS / NEAR O;�t2 PARCEL N(OPTIONAL) <br /> CITY NAME /' STATE ZIP ! SITE,PHONE 0 WITH AREA CODEI/ BOX CA <br /> \ <br /> TO INDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' �1 <br /> If owner of UST is a public a ncy,complete the following:name of Supervisor of division,section,or office which operates the UST e <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN ISOFTANKSATSITE I E.P.A. 1.D.#(goticnal) <br /> RESERVATION <br /> Q 3 FARM Q 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 of WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> do <br /> G M LI STRErmTADDRESSboxloindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> It <br /> Mv. S� - Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> aW NAME STATE ZIP CODE._ PHONE#WITH AREA CODE <br /> S 1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q 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 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q NSURANCE - 4 SURER BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION 49 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless Ox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.EV II.= 111. <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 M01T Y/Y R <br /> g Z <br /> LOCAL AGENCY USE ONLY <br /> _14�_be (� <br /> s u <br /> COUNTY# JURISDIC�TION# FACIL <br /> W, �� rfY <br /> W" 9_a±N_a12L <br /> LOCATION CO OPTIONAL CENSUS TRACT#- I OV I0077QUAL SUPVISOR-DISTRICT OP Ulf V <br /> 31 3 <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 REGULATIONS �G <br /> FORM A(3(93) FOR=3A•R7 <br />