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0 <br /> tt�R P <br /> STATE OF CALIFOFNA Ave <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMITAPPLICATION-FORM A <br /> I <br /> COMPLETE THIS FORM FOR EACH FACILtTY/SI CE+ <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> PlIN{ M41t7f c <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> M97 y0.5rrff AVG:` <br /> CITY NAME STATE ZIPJPODE 81TE PHOiPE#WITH AREA CODE <br /> CA CWCA ®/ <br /> TOINIaCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:narne of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS / GAS STATION Q 2 DISTRIBUTOR Q ✓ IF ERV <br /> INOIAN #OF TANKS AT SITE E.P.A. I.D.#(gotlwnal) <br /> RESATION <br /> 0 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS <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 /> 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 /> / <br /> MAILING OR STREET ADDRESS ✓boxbIndicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Z05`7 WY_Ln_6Zr_ — Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE PHONE#WITH A A CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1097 Y49zw MI 7q,(cQ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE#WITH AREA CODE 2,S1 <br /> J r <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q W 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: 1.0 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 MONTWDAY/YEAR <br /> SEAd VA <br /> LOCAL AGENCY USE <br /> COUNTY If JURISDICTtON# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPT10N4L <br /> THIS FORM MUST BE ACCOMPANIED BY ATL T(1)OR MORE PERMIT APPLICATION• FORM B,UNL IS A CHANGE OF SITE RfORMATION ONLY. <br /> OWNER MUST FILE THE FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU 8TORAGE TANK REGULATIONS <br /> FORMA(3 9:i) FM-R7 <br />