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OUNCES <br /> STATE OF CALIFORNIA <br /> Ar <br /> t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A r� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 ANGE OF INFORMATION 0 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT = 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF G" OPE TOR <br /> Nc-v�2o�1 /gTio�1S .�•t/er <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1%o // Td -,ST <br /> CITY NAME STATE ZIP OD-E SIV PHONE#W H AREA CODE <br /> CA <br /> ✓BOX CORPORATION ED INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' F-1 STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '9 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 X 1GAS STATION Q 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS OQ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LA T,FIRST) PHO #WITH REA CODE <br /> / Ai <br /> NIGHTS: NAME(LAST IST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON, WITH AREA CODE <br /> / / V/ (J�/ <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAJAg CARE OF ADDRESS INFORMATION <br /> (LING OR STR AD RESS ✓ box to indicate INDIVIDUAL =LOCAL-AGENCY STATE-AGENCY <br /> 40- in Kf✓(O CORPORATION (] PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY <br /> Cl AME STATE ZIP ODE PHONE#WITH AREA CODE <br /> n�J^K <br /> III. TAWK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CA5LE OF ADDRESS INFORMATI <br /> M G OR STREET ADDRESS ✓ box to ndicat = INDIVIDUAL =LOCAL-AGENCY STATE-AGENCY <br /> DO VC CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY E�] FEDERAL-AGENCY <br /> CI 111 AM <br /> SVATE ZI�ODE �E#WIT A CO oQ <br /> O d—J <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to intricate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.0 III.ru", <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK/O�WNNE�R'S NIAM PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MO`NTHIDAYNEAR <br /> LEZ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ED <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT a(1)OR MORE PERMIT APPLICATION- FORM B,UNLESIM IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM M THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLIMTORAGE TANK REGULATIONS �•-'A14 <br /> FORM A(6-95) JOU <br />