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0 i <br /> STATE OF CALIFORNIA PAY ` <br /> o^ <br /> STATE WATER RESOURCES CONTROL BOARD R GC 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITESAN1'��.Qi !:.''�`".` a" 1 Y <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONIpViQl6 �tii!L7y '��✓<•.Ji J <br /> ONE ITEM F_� 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> W v <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> L �irt c <br /> CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> S-� G CA <br /> ✓BOX CORPORATION I—I INDNIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '#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 0 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR ®5 OTHER OR TRUST LANDS ®dv <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) PHON #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 /> C-0 r-;Qd6zEtjc5Q7__ <br /> MAILING OR STREET ADDRESS ✓ box to indicate [:]INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O �� v ORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE Pyi%NE#WITH AREA CODE <br /> CGS as `/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> • P4 <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> C-> 83 ETI�CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEP ONE#WITH AREA CODE <br /> C COC7 -7 — S <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- I4��°`�`y` <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 :INSURED a 2 GUARANTEE 1-7 3 INSURANCE [=)4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> l__1 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND 6 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= It.D III. <br /> THIS FORM HAS BEEN COMPLETED U R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> K OWNER'S NAME(PRINTED&SIGNATURE) 'S TITLE DATE MONTH/DAYNEAR <br /> G7r' • <br /> F/L ltC. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATM(1)OR MORE PERMIT APPLICATION- FORM B,UNLESM IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) a-A-A 1 W <br />