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1 <br /> STATE OF CAUFOTWIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ate, <br /> COMPLETE THIS FORM FOR EACH F ITYISITE `'xrroar" <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT EVf5 CHANGE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM ❑ 2 INTERIM PERMIT 1❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARER CROSS STREET PARCEL a(OPrIDNAu <br /> CITY NA STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> CA <br /> ✓ IOX CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY <br /> TO INDICATE DISTRICTS' CWNfV-AGENCY' D STATENC <br /> AGEY• O FBIERAL-AGENCY' <br /> H owner d UST is a public agency,coplte IM following:name of Supervisor of d"lon,section,or oNlcs which operates the UST <br /> TYPE OF BUSINESS '��STATION ❑ 2 DISTRIBUTOR / IF INDIAN❑ RESERVATION <br /> a Of TANKS AT SITE E.P.A. I.D.a(gNbnap <br /> LZ 3 FARM ❑ 4 PROCESSOR [--15 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE n\ DAYS: NAME(LAST.FIRST) PHONE a WITH AREA GORE <br /> (/V <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDR��S ✓ bulaintlNam I� INDIVIDUAL LOCAL-AGENCY I�STATEAGENCV <br /> Ff� s�. ! O CORPORATION I3 PARTNERSHIP O COUNTYAGENCY O FEDEMLAGENCY <br /> CITY NAM STATE ZIP CODEPHONE a WITH AREA CODE <br /> v O I Ola <br /> III. TANK OWNER INFORMA ION-(MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Irdbae 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION E--1 PARTNERSHIP O ODUMYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkale l�1 SELF-INSURED =12 GUARANTEE O 3 INSURANCE 4 SUBETYBOND <br /> 5 LETTEROFCRED(T =6 EXEMPTION E=1 W 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 cheI <br /> CHECKONE 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 /> OWNERSNAME(PRINTED&SIGNED) OWNER'S TRLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION a FACILITY# <br /> KI 5EA04 I I 1 1 lei <br /> LOCATION CODE -OPTIONAL CENSUS TRI•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 ONL . <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3931 Fqp013MV <br />