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STATE OFCAUFORNIA V <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a COMPLETE THIS FORM FOR EA ACILITYISITEMARK ONLY ❑ 1 xEW PERMrt <br /> ONE REM ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O <br /> ❑ 2 INTERIM PERMIT 6 TEMPORARY SITE CLOSURE <br /> ❑ A AMENDED PERMIT T PERMANENTLY D 917E <br /> I. FACILITY/SITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> DSA FACILITYN E <br /> I[� NAMEOFOPERATO <br /> ADORESSq <br /> ` <br /> CITY NAME NEAREST CROSS STREET PARCEL#(OPTXNMU <br /> STATE ZIP CODE SITE PHONEi WRH AREA CODE <br /> ✓ BOX CA <br /> TOINDICATE PORATION Q INDIVIDUAL C1 PARTNERSHIP Ej LOCAL-AGENCY CD COUNTY <br /> 'N caner d UST is a Pudic agen m DISTRICTS' AGENCY,• 'ATE <br /> ED FEOEIML#GENCY' <br /> rrWde the Idbw4p:nartle d Supervbp d ONkbn,aeclbn,a dlim whbh <br /> TYPE OF BUSINESS ❑ OPwat%the UST <br /> LK 1 GAS STATION 2 DISTRIBUTOR O RESERVATION <br /> i OF TANKS AT SITE E.P.A 1.0.#Ibb,,,o <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Ppt[MW <br /> [DAYSq:NA ME(LAST,FIRST) 9WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE WITH AREA CODEGHNAME T,FIRST) PHO #WITH AREA CODE NIGH S:NAME(VST,FIRST) ` '/ <br /> 0 HONE#WITH AREA CODE <br /> if. PROPER OWNER INF RMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> 1L T <br /> MAILING OR STREET ADDRESS ✓bublMbax 0 INDIVIDUAL =LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP =COUNTY AGENCY =FEDERALAGENDY <br /> CITY NAME TA ZIP H WITH AREA CODE <br /> 4 0 - D <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOf NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓aubiMNaY INDIVIDUAL LOCAL AGENCY O STATEAGENCY <br /> f�CORPORATION O PARTNERSHIP -1 COIJ!OfWENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 z(o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bob kld y =1 SELF INSURED Q 2 GUARANTEE 0 3 INSURANCE A SUflETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.0 III.❑ <br /> THLS FORM WAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'STTTLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY i JURISDICTION i FACILrrY i <br /> ® t"' 9 <br /> -LOCATION-CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL TSUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHS IS A CHANGE OF SITE INFORMATION NL . <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA 1393) Pg160MA7 <br />