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• � tbOup C <br /> STATE OFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD rt mfr a o° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �40ropt <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED E <br /> ONE ITEM F-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPER OR <br /> ce�wle�� was - �a� J ,1` <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME --' � STATER ZIP CODE SITE PHONE#WITH AREA CODE <br /> G <br /> BOX <br /> TOINDICATE O CORPORATIONDIVIDUAL PARTNERSHIP ED LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' = FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency rrplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN l#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA: NAME(LAST,FIR T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (�.( C �i i r Z09 63— S 2 9! <br /> NIGHTS: NAME AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGOR ST EET ADDRESS ✓box bindicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 3 -) ® A0 /Qr_ CORPORATION PARTNERSHIP (]COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME �G ST�OE ZIP CODEPHONE#WITH AREA CODE <br /> ✓d . /r- 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate 0 INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> (�CORPORATION ED PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY 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) HIDM44- - o a y T & 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 1 SELF-INSURED (]2 GUARANTEE 0 3 INSURANCE �+1 4 SURETYBONDo <br /> f� 5 LETTEROFCREDIT Q 6 EXEMPTION OTHER J/"� �t/N�/ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Fm 23_ 1_ 'S 1-7 K/ I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL I SUPVISOR-RISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FO M 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 /> FORM A(3/93) "vQ' vv FOR0033A-R7 <br />