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`• ' � fY1111 <br /> • STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; 1 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �& NEW PERMIT Fj 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE Thr <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY N E ( NAME OF PERATOR <br /> ADD E L111 (-� NEARES SS STREET PARCEL e(0 NAL) <br /> 1131y 00 v l <br /> CITY NAME,-1--D STATE ZIP PHOPig:x WITH AREA COD <br /> in Cca, b a— <br /> I/ BOX <br /> TO INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY I]COUNTY-AGENCY STATE-AGE N Y' 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 a t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION 4 <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS x <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( T.FIRST) / _ PHONE s WITH AR A COODE DAYS: NAME(LAST.FIRST) PHONE to WITH AREA CODE <br /> NIGHTS: WME(LAST.FIRST) PHONE X WITH AAWA CODE NIGHTS:NAME(LAST.FIRST) PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFO RMA ON <br /> u 's], L-06w- Twljock(� <br /> MAILING OR STREET DRESS ✓box bIntlieate 0 INDIVIDUAL LOCAL-AGENC STATE-AGENCY <br /> (�CORPORATION (] PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE o WITH AREA CODE <br /> 9? �' — 3 S <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 LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate t SELF-INSURED o 2 GUARANTEE (] 3 INSURANCE Q 4 SURETY BOND <br /> O 5 LETTER OF CREDIT Q 6 EXEMPTION go 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. 11. 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&SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION S FACILITY# 3,2`­10 <br /> 1.3 1 / jV 0 l u <br /> LOCATION CODE--OPTIONAL CENSUS TRACTS •OPTIO R h 3UPVISOR-DISTRICT CODE <br /> ^4 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATICk NLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FOR00�9Afl7 <br /> OU"e ��a� I -A3 —cls <br />