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`boun . <br /> STATE OF CAUFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD ;40 r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A 0 <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TE <br /> ONE REM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRE S-(MUST B COMPLETED) <br /> DBA OPWILIm <br /> NAME OF OPERATOR <br /> ploh oe"55\1 (W (45h <br /> ADORES STCROSSST ETo PARCEL#(OPrIONAL) <br /> 0�ti�J , <br /> CITY STATE ZIP—CME SITE PHONE If WITH AREA CODE <br /> C&M I CA <br /> ✓ x LOCAL-AGENCY <br /> TO INDICATE O CORPORATION =INDIVIDUAL (]PARTNERSHIP DISTRICTS' COUNTY-AGENCY' E::]STATE-AGENCY FEDERAL-AGENCY' <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 0 / IF INDIAN RESERVATION #OF TANK T SITE I E.P.A. I.D.#(optional) <br /> Q 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <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) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n ` Chi F ADD ESS NFORMATI <br /> R, <br /> MAILIN R STRE DRES ✓ z bindic INDIVIDUAL LOCAL-AG ENCY STATE-AGENCY <br /> t =CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITYN ,. I ST/rjE n ZIP E � PHONE# TH ARBA CODE <br /> bn Li <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /�-�GLJ <br /> I- <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (�CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 M44- dni-& <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b Indicate O 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE [=1 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: I.❑ II.❑ 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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> q,0 <br /> LOCATION GQ OPTIONAL CENSUS TRAC # -OPT 3UPVISOR-DISTRICT CODE -OP <br /> ol <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS A CHIANGlk OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIS <br /> FORMA(3193) i'/ FOfi0033A•R7 <br />