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ou <br /> STATE OF CALIFORNIA w! <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E::] 7 PERMANENTLY CLOSE <br /> 7] <br /> ONE ITEM O 2 INTERIM PERMIT E::] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ?J <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) �4P c1 D <br /> SRA OR FACILITY NAME / NAME OF OPERATOR <br /> ADDREESS. NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> r..l CA '7v`" r <br /> I/ BOX <br /> T NDICATE E:]CORPORATION INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY 0 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 <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR a ✓ IF INDIAN I#OFT AT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION J_ <br /> (� i� OR TRUST LANDS (jJ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 7#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A 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 /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME� STATE ZIP CODE� /� PHONE rt WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ! ) CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> %4S l� =1 CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> z_..Gtr C,-4 <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 /> ✓ <br /> box bIndicate O 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE (]4 SURETY BOND <br /> O 5 LETTEROFCREDIT 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: <br /> TH/S 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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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(3193) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM I�r�Pd <br /> � - - <br />