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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W 4a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITY NAME NAME OF OPERATOR I A(e <br /> N p � e-, <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> 3-t c, CA Q S?_O(o <br /> BOX <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' 0 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 rXj1 GAS STATION a 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q 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 /> PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 2 !v <br /> M LING OR STREET ADDRESSES ✓ box b indicate INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> ©' S O O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME ST TE ZIP C DE PHONE#WITH AREA CODE <br /> Cc E 135-31 9 6 z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /V <br /> MAILING OR STREET ADDRES ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> S0"6 D CORPORATION ==PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY y�ME Y _ / STATE _ ZIP OD�3 / PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. b/ <br /> TY(TK) HOF4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 0 1 SELF-INSURED 2 GUARANTEE (]3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 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: I.❑ 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 8 SIGNED OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> 6 <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> ❑ ❑m .),1 3 It 10 q Z- <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL 3UPVISOR-DISTRICT CODE -OPTIONAL <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) 9 9 FOR0003A4i7 <br />