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0 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY F__]t NEW PERMIT 3 RENEWAL PERMIT E�] 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO E <br />ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ©� <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBAORE NAME <br />NAME f OPERATOR <br />t <br />(] <br />Q 'R.. <br />t O - <br />ADDPXSS <br />1 <br />NEA '98TCRO EET <br />i; <br />PARCEL #(OPTIONAL) <br />CITY NAME <br />3T19'(B <br />2tP CODE <br />SITE HONE # WITH AREA CODE <br />co <br />10A <br />if / <br />T NDBI ATE D CORPORATION = INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY' 0 STATE -AGENCY' Q 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 t GAS STATION 2 DISTRIBUTOR <br />IF <br />0 <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (opdanal) <br />3 FARM 4 PROCESSOR Q 5 OTHER <br />SERVATION <br />REV <br />OR TRUST LANDS <br />I <br />I <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST. FIRST) PHONE # WITH AREA CODE <br />DAYS: -NAME (LAST, Fl STI PHONE JITH AREA CODE <br />..i o, tj A8 11(j <br />NJOHTS: NAME (LAST, FIRST) PHONE # WI H AREA CODE <br />NIGHTS: N (LAST, FIRST) PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAMt- ( , & <br />t <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box b indicate 0 INDIVIDUAL 0 LOCAL -AGENCY Q STATE -AGENCY <br />L4 rl Lo <br />(] CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP <br />PHONE # WITH AREA CODE <br />CODE <br />( � 1 <br />D(c <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAMEVOW ER <br />CARE OF ADDRESS INFORMATION <br />i <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />S. C <br />CORPORATION O PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATEZIP <br />CODE <br />PHONE # 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- - D .2 14 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />5 LETTER OF CREDIT 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: 1.0 if. [:j 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 MONTWDAYIYEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTKNI0 FACILITY # <br />LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OP77ONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE WIDRMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU STORAGE TANK REGULATK IS <br />FORMA (3/93) 0 � FOR0033A-A7 <br />I <br />