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STATE OF CALIFORNA <br /> STATE WATER RESOURCES CONTROL BOARD 3.,� :o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4���on+`' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORJACILTIJAME NAM OPERATOR <br /> ADDR SSS N A STCROSS ST ET PARCEL 0(Ol TIONAL) <br /> {I) 1 <br /> CITY NrEJD� STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> V Box <br /> TO ININCATE CORPORATION Q INDIVIDUAL I=PARTNERSHIP O LOCAL-AGENCY COUNryaOENCY' O STATE-AGENCY FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner d UST N e pubic agency,corrylete the following:name of Supervisor of division,section,or oNloe which operates the UST <br /> TYPE OF BUSINESS O I GAS STATION 0 2 DISTRIBUTOR O ✓RESERVATION INDIAN a OF T AT SITE E. <br /> RESERP.A. I.D.A(optiorW) <br /> 3 FARM 0 4 PROCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS LVz V ✓ box bbNcab O INDIVIDUAL (] LOCAL-AGENCY O STATE- <br /> AGENCY <br /> CORPORATION O PARTNERSHIP (] COUNrYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbbokaN INDIVIDUAL LOCAL-AGENCY E13 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY ED FEDERALAGENCY <br /> CITY NAME STATE 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) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓boy bMkae 0 I SELF-INSURED Q JAUARANTEE (] 3 INSURANCE 4 SURETY SONO <br /> 5 LETTEROFCREDIT B EXEMPTION Q 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: 1.J= II.O 111. <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 x JURISDK:TKNd a FACILITY s �� <br /> LOCATION CODE 1TONAL CENSUS�RA�Tfe 9UPVI30R- 15��DE T10 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM BUU LESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) (\ FOR0097AA7 <br /> '�A <br />