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C,,OVA <br /> p C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY t NEW PERMIT � 3 RENEWAL PERMIT O 5.CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> !C STAT)ofQ Sr T,XeA f=F )N ®P�, Epps!; <br /> ADDRESS I NEAREST CROSS STREET y PARCEL#(OPTIONAL) <br /> (' k1 g-1Pi --V <br /> CITYhlAME� STATE ZIP_PODE { SITE PHONE 0WITH AREA <br /> tCODE <br /> ✓ Box CORPORATION (�INDIVIDUAL E:1 PARTNERSHIP (]'LOCAL-AGENCY ED COUNTY-AGENCY' �STATE-AGENCY' � FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> N owner of UST is a public agency,complete the following:name of Supervisor of division,sedan,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR = `✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS Z <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 /> ry RT_AtIGHT <br /> S: NAME(LAST,FI T) HONE#WITH AREA CODE NIGHTS;NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> / 4q.S <br /> 74 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> sam-L, oic- a-�MPA_fvq <br /> MAILING OR STREET ADDRESS ✓box blntlicats = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> ®� -t IKCORPORATION O PARTNERSHIP =COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bMdicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> f , <br /> o® CORPOO ON O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAMESTA ZIP CODE HONE WITH AREA CODE <br /> S <br /> 4 452S! /�1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER Call(916)322-9669 if questions arise. <br /> kYHQ3 -�- <br /> V. PETROLEU ST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxthdieate SELF-INSURED 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTEROFCREDIT 0 a-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 /> 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) OWNERS TITLE fA DATE MCOITWDAYNEAY <br /> ,25 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77ONAL SUPVISOR-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 /> OWNER MUST FILE THIS FORM wrti i`THE' LOCAL AGENCY NTING THE UNDERGROUND STORAGE TANK REGULATUM <br /> FORM A(3193) ® F3A-R7 <br />