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STATE OF CALIFORNIA �� a <br /> STATE WATER RESOURCES CONTROL BOARD Y 4a 1 d 8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 40paRN1' <br /> MARK ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT X 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> > DBA OR FACILITY NAME QUAF5 'E rJo3al ry)rt_rT NAME OF OARATOR ­00 <br /> ADD ESS 0 �- 'J NEAREST bROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME71-4? ST CEA S <br /> ZI CODE (J> SITE PHONE#WITH AREA CODE <br /> I/ Box TOINDICATE (�RPORATI N (]INDIVIDUAL (]PARTNERSHIP LOCAL-AGENCY QCOUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of d"ion,section,or office which operates the UST <br /> TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTORFIOR <br /> ✓ IF INDIAN #OANKS AT SITE E.P.A. I.D.#(gotional) <br /> RESERVATION <br /> 0 3 FARM ❑ 4 PROCESSOR E=] 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY • AME(LAST,FIRST) PHONE#WITH AREA CODE D S: NAME T,FI� PHONIWITH AREA CODE <br /> msv— <br /> NIGHTS: NAME(LAST,F T) PH NE#WITH AREA CODE NIGHTS: NAME T.FIR T) PHONE#WITH AREA CODE <br /> la-1 4 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 3 <br /> ,�fr,4 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET RESS ✓ bo b irate � INDIVIDUAL � LOCAL-AGENCY � STATE-AGENCY <br /> ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> C��� � ��r. STATE ZIP CODE PHONE#WITH AREA ODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER J/ /,, CARE OF ADDRESS INFORMATION <br /> fV 173 <br /> MAILING OR STREET ADDRESS ✓box bindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP 0 COUNTY-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 F4-14--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box toindicate 0 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE (]4 SURETY BOND <br /> 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.❑ II-X 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 TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILnY (0 3Q8 <br /> EE � 3 I ! I y <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 3UPVISOR-DISTRICT CODE -OP77ONAL <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 FORM0WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRTORAGE TANK REGULATIONS <br /> NS <br />