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• tbo�a � <br /> STATE OF CAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD W m0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A rr <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT ► CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIE ITY NAME NAME OF OPERAT / /;�I` <br /> ADDRESS4 & & NEAREST CROSS STR /PARCEL 9(OPTIONAL) <br /> Y.3 <br /> CITY Nf A STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> /// e cGrL CA /fes <br /> I/ Box <br /> TOINDICATE D CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY- Q 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 t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D=T,( ST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) it PHONE#WITH AREA CODE NIGHT 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 oZ S LCiq v1 box to Indicate 0 INDIVIDUAL 0 LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION = PARTNERSHIP = COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITU NAME e STA ZIP CODE PHONE#WITH AREA CODE <br /> c �s- o y <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 4177-34113 <br /> NAMEOF OW NE CARE OF ADDRESS INFORMATION <br /> / /7 7 e de" <br /> MAILING OR STREET ADDRESS a� 5 ./ box b indicate 0 INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION = PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM =SaT __7Z1P CODE ., PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. t'%7-�?0'13 <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 1 SELF-INSURED Q 2 GUARANTEE (] 3 INSURANCE <br /> D 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: 1.= 11.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'SjdtnE PR/-31 1f7ll�� OWNER'S TITLE DATE MONTWDAY/YEAR <br /> `/J1 jj//JJ ��..55 4J �i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY,# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 NFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKM <br /> FORMA(3/93) FOR0033A-RI <br /> i <br /> Lq <br />