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t6puR C <br /> STATE OF CAUFOFNA <br /> STATE WATER RESOURCES CONTROL BOARD i,nor S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1 t NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY G OSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F—I 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE �� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D8AAjFACILITY NAM �� NAME OF OPERATOR <br /> aC , r f <br /> ADD ESS J NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP E SITE PHONE#WITH AREA CODE <br /> L C. 0 / CA <br /> T 10 Nq pp TE CORPORATION 0 INDIVIDUAL �PARTNERSHIP Q DISTRICTS'LOCAL-AGENCY COUNTY <br /> •AGENCY' 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 f GAS STATION Q 2 DISTRIBUTOR RESERVATIONIF INDAN #OF TANKS AT SITE I E.P.A. I.D.#IcWional) <br /> 0 3 FARM O 4 PROCESSOR 0 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 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL LOCAL-AGENCY E::]STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL•AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> rNAME( <br /> PACIFIC BELL-PERMIT DESK QED) <br /> CARE OF ADDRESS INFORMATION <br /> P. O.BOX 15038 <br /> 2646 WATT AVENUE, SUITE 4 box to indicateSACRAMENTO,CALIFORNIA 95851 = INDIVIDUAL Q LOUNTY-GEN STATE-AGENCY <br /> CORPORATION � PARTNERSHIP 0 COUNTY-AGENCY � FEDERAL-AGENCY <br /> ATTENTION: LOUANA J.URIBE STATE ZIP CODE PHONE#WITH AREA CODE <br /> TION UST ST UNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box lo,indicate 1 SELF-INSURED 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT (]6 EXEMPTION (]99 OTHER <br /> A. 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 it.[::] III.X <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 &ftl <br /> COUNTY# JURISDICTION# FACILITY# <br /> a4 FTTI I I E= <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 /> FORM A(3/93) FOR0033A t{7 <br />