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g <br /> .{ '. <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W der a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '' <br /> C11/OPN <br /> t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> MARK ONLY ❑ ❑ ❑ ❑ ; <br /> ONE ITEM ❑ 2 INTERIM PERMIT F-1 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O F ILITY NAMENAME OF ER TOR <br /> 5 - "' ff a7--0 <br /> ADDR Sy.�,�..r+ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> L:..4aC, <br /> CITY NAME STATE ZIP ODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' D STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE 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 BUSINESS1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> "" ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11, <br /> II. PROPERTY OWNER INFORMA ON-(MUST BE COMPLETED) ! <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY { <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 <br /> III. TANK OWNER INFORMATION-(MUST BEOMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxtoindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE 7 CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOU NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]74- -1I 1 T—F] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SUR"OND 0 5 LETTEROFCREDIT 0 6 EXEMPTION 0 7 STATE FUND 1 <br /> D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFItTE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM O 99 OTHER <br /> I <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and b ing 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 NOTIFICATIONSA D BILLING: I.❑ It. Ill.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE EIT OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 4�a 771 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> i <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 FORMAim7H THE LOCAL AGENCY IMPLEMENTING THE UNOERGR01' STORAGE TANK REGULATIONS <br /> FORM A(6-95) (X�/ <br /> I <br />