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STATE OF CAUFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />�i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , ;s <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE �4vonN'' <br />MARK ONLY t NEW PERMIT a 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION E 7 PERMANENTLY CLOSED SITE <br />ONE REM 0 2 INTERIM PERMIT F-14 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE / <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />NIGHTS: NAME (LAST, FAST) PHONE4 WITH AREA CODE <br />YID <br />CIS <br />STATE <br />ZIP CODE <br />ADDSSAU) <br />IttIA7 <br />NE EST CROS§ STREET <br />PARCEL #(OPTIONAL) <br />CITY NAME,.— <br />S ATE ZIP C E <br />-, Q <br />SITE PHONE # WITH AREA CODE <br />Q L <br />CA <br />✓ Box <br />TO INDICATE <br />CORPORATION INDIVIDUAL = PARTNERSHIP <br />Q LOCAL -AGENCY( OUNTY-AGENCY' <br />(] STATE -AGENCY' FE ERAL-AGENCY' <br />DISTRICTS' > ` y- <br />It owner d UST is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST Q/t <br />/� <br />\ 7 - <br />TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 0 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ontlonal <br />DAYS: NAME LAST, FIRST) PHON # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FAST) PHONE4 WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to Indicate 0 INDIVIDUAL LOCAL -AGENCY E�] STATE -AGENCY <br />F7 CORPORATION Q PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY <br />CORPORATION Q PARTNERSHIP OUNTY-AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE c <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) HO4 4- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate (� t SELF-INSURED (] 2 GUARANTEE Q 3 INSURANCE 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: 1.154 II. 0 III. O <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 # JURISDICTION # FACILITY # <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL 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 REGULATIONS <br />FORMA (3193) c� �j c � FOR0033A-R7 <br />�nl/ <br />