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MARK ONLY <br />ONE REM <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DB OR <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />1 N�DEERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />A" 1 "7 IX /�. COMPLETE THIS FORM FOR EACH FACILITY/SRE <br />a 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY <br />a 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br />ITY N <br />DAYS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />NIGHTS: SAME (LAST, FI ST) 'PHON6 #WITH AREA CODE <br />NAME OF OPERATOR <br />ADDRESS <br />5 <br />f� CORPORATION Cj PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />,, <br />NEAREST CROSS ET <br />S <br />PARCEL 0 (OPTIONAL) <br />CITY NAME <br />C_ik <br />STATE <br />CA,5 <br />ZI CODE <br />S TE PHONE STH AREA CODE <br />TOINDICBOX <br />= CORPORATION <br />[ INDIVIDUAL Q PARTNERSHIP <br />Q LOCAL -AGENCY 0 COUNTY -AGENCY ' STATE -AGENCY' (] 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 1 GAS STATION 2 DISTRIBUTOR= <br />0 3 FARM Q 4 PROCESSOR 0 5 OTHER <br />'/IF INDIAN <br />RESERVATION <br />OR TRUST LANDS <br />s OF TANKS AT SITE <br />a <br />E.P.A. I. D. # (optional! <br />FMFRr,FNr.Y CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - oodonal <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />NIGHTS: SAME (LAST, FI ST) 'PHON6 #WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />u 00nDC0TV nWKICR INFnQRAATInKI . IMI IST RF CnMPI-FTFD1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR ST ADDRESS <br />✓ box lo eMicats INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />f� CORPORATION Cj PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />,, <br />CITY NAME <br />STATE ZIP CODE PHONE # WITH AREA CODE <br />C_ik <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER I CARE OF ADDRESS INFORMATION <br />I MAILING Oli STREET ADDRESS ✓ box 101m cats L&,INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY <br />O CORPORATION E:j PARTNERSHIP 0 COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME STATE I ZIP CODE I 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—F4]- - D 1 3 I r7 I 011W <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box tolndkcate 0 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT -1 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. Q 1, 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 # <br />0 <br />JURISDICTION # FACILITY # <br />CODE - OPTIONAL <br />CENSUS TRACT# -OPTIONAL SUPVISOR- DISTRICT CODE - OPTKWAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFOR <br />OWNER MUST FILE THIS FORW THE LOCAL AGENCY111P IONS <br />UNDERGROUND STORAGE TANK REGULAT <br />FORM A (3193) � <br />to <br />