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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W 4a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °4k,romo" <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> O <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE f�0 A <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR j <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> LAD�K�fo�r� <br /> CITY NAME STATE ' ZIP CODE SITE PHONE#WITH AREA CODE <br /> '� T CAV BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' 0 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 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN IN OF TANKS AT SITE E.P.A- 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYYYSSS:,(N ME( ST,FIIRRS�TT). /� PHONE#W7ITH AREA�COODE 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 /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1q4__7A/,k �5iv . <br /> MAILING OR STREET ADDRESS ✓box bindicate INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> Z_2'7 CORPORATION PARTNERSHIP (] COUNTY-AGENCY (]FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE L PHONE#WITH AREA CODE <br /> J � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFAOWNER <br /> ,/ CARE OF ADDRESS INFORMATION <br /> -'`�✓—/��LVii! <br /> MAILING OR STREET ADDRESS ✓box lo indicate l� INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> ,f7/_;, L CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CO 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 F4-T4-1- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 1 SELF-INSURED =2 GUARANTEE (]3 INSURANCE <br /> 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =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.[:] if III. <br /> = ::1 <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 /> 9 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL 9UPVISOR-DISTRICT CODE -OPT70NAL <br /> /v z �6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS LS A CHANGE OF SITE ORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3193) � � FOROIX43A-R7 <br />