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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED. <br />ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME)I <br />,- �S <br />NAM OPERATOR <br />d' M Cal <br />, S R <br />a,/,/ <br />ADDRESS� � <br />'?s <br />NEAREST SS STREET <br />PARCEL # (OPTIONAL) <br />CITY NAMEr 0 <br />STACEA ZIP COD <br />SITE E� WITH ARE/�CODE�� <br />CS <br />GP�HON <br />��(( <br />✓ BOX Q CORPORATION VCI INDIVIDUAL D PARTNERSHIP O LOCAL -AGENCY COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' <br />TO INDICATE /X DISTRICTS <br />' N 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 1 GAS STATION Q 2 DISTRIBUTOR <br />0 ✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE It WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE If WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMIPLFTFD) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ bcx to irez e 0 INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />CORPORATION = PARTNERSHIP Q COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE It WITH AREA CODE <br />III- TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />0 CORPORATION Q PARTNERSHIP O COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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 4 4-1-10 5 o <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION O 7 STATE FUND I <br />6 STATE FUND d CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT 0 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: 1.0 it. a III. a <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAY/YEAR <br />LOCAL AGENCY USE ONLY -T <br />COUNTY # JURISDICTION # FACILITY # 10 °1 <br />ED <br />LOCATION CODE - OPTIONAL ICENSUS TRACT # - OPTION& I SUPVISOR - DISTRICT CODE - OPTIONAL n (I n 1 i <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFUHMAI IUN UNLY. <br />FORMA (6-95) <br />OWNER MUST FILE THIS FOR1W THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br />4 0 — ii' % X46 <br />