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'�C•�uuq <br /> STATE OF CALIFORNIA <br /> r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOS <br /> ONE ITEM R-2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBABR FACI �E NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL M(OPTIONAL) <br /> 1��£r"7Z i��1 fc <br /> CITY NAME STATE ZIP DE � ITE PHINE#WITH AREA CODE <br /> CA <br /> T IO NDIICATE CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' (]STATE-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 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(options!) <br /> FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERG CY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N (LAST,FIRST) PHONE#WITH RE CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Q 69 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHARREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0/2:7 <br /> II. PROPERJY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR REET ADDRESS ✓ box bindicate 0 INDIVIDUAL 71 LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION = PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME P STATE A ZIP CODE HONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF N R '4 <br /> �z CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRE ✓ boz b ind cafe 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> L _ f�j (�CORPORATION PARTNERSHIP COUNTY-AGENCY (� FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CO 7 ;OFN9 yJ EA CO <br /> IV.4BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-966(9 if questions arise, l{ <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT Q 6 EXEMPTION 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. II.Ls[ Ill.= <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/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVIS R-DISTRICT CODE -OPITOAUIL <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 REGULATKMIS <br /> FORMA(3/93) 9 FOR0033A-R7 <br />