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F" _ 1 <br /> 4 <br /> ! STATE OF CALIFORNIA ,d <br /> STATE WATER RESOURCES CONTROL BOARD <br /> .� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Opapt <br /> MARK ONLY NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE_ <br /> ONE ITEM Q 2 INTERIM PERMIT E:14 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAYE C NAME OF PERATOR <br /> J <br /> ADDMESS 3 <br /> , SS STREET PARCEL#(0 NAL) <br /> CITY NAME,- � � STATE CZIP D� �PHO E#WITH AREA CO <br /> A D <br /> I/ BOX <br /> G <br /> T INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COU ' Q STATE•AGEN V' Q <br /> NTNTY•AGENCYFEDERAL-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 = I GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L T,FIRST) _ PHONE#WITH AR A CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ti 0 a— <br /> NIGHTS: WME(LAST,FIRST) PHONE#WITH ARVA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMA ON <br /> 4�S l � oc <br /> MAILING OR STREET DRESS ^� ✓box bindkate Q INDIVIDUAL Q LOCAL-AGENC QSTATE-AGENCY <br /> p', Q CORPORATION Q PARTNERSHIP Q COUNTY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME,--t, STATE ZIP CODE PHONE#WITH AREA CODE <br /> /} b <br /> C� ) ` 3 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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) HQ F4-T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate Q ISELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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. it. 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) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION ODE_-OPTIONAL CENSUS T CT#-OP SUPVISOR-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 REGULATM <br /> FORMA(3/93) `/ � FOR0033A•R7 <br /> • ��� _Fa4t �-K-& *0&1, � 7 l — 7,f:)A3 c <br />