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0 U. l <br /> fJ' �u• C <br /> STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD r mfr c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY)SITE <br /> MARK ONLY F-1 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> Fn—FIA 09 FACILITY NAME NAME OF OPERATOR <br /> Z,01 <br /> acJwvD G/ v 5i <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODg SITE PHONE#WITH AREA CODE <br /> r CABOX <br /> ` D <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 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 F--] t GAS STATION 0 2 DISTRIBUTOR RESEIF RVA <br /> # OF TANK AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT 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 /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL [] LOCAL-AGENCY STATE-AGENCY <br /> `L `4.,. /� S� Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME,�C STATE ___FZ_1PC0DED /� PHONE#WITH AREA CODE <br /> III.LTANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> V— (]CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> m F,- ZC/p <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -11 111 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED (]2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT Q 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: I.E II. 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 MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 ' r <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 I ON bNLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3/93) 0 0 FORpp3&A-R7 <br />