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(•: OVA �' <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F_� 1 NEW PERMIT 0 3 RENEWAL PERMIT urs, CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREqq <br /> i. I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) < <br /> DBA FACILITY NAME NAMEOFCPERATOR <br /> i <br /> ADOM83 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE x WITH AREA CODE <br />! CA C40 2 p <br /> f T INDI AC T <br /> OE CORPORATION = INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> C 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 LZ"l GAS STATION 2 DISTRIBUTOR RESEIF RVATION s OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE K WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGO STREET ADORES ✓box bindicateINDIVIDUAL i1 LOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION 0 PARTNERSHIP [�:] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE PH E#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 b indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ®CORPORATION = PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -1012 Iq <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate 0 1 SELF-INSURED 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 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 /> F <br /> ECK 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) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY;r <br /> 2 / Rm .5=�5=9 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SIIPVISOR-DISTRICT CODE -OP710NAL r <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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � � FORPOWN <br />