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C6 yP C <br /> / STATE OF CALIFORNIA :`' c o <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ';� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE t�•ae"'• <br /> MARK ONLY F7 I NEW PERMIT O 3 RENEWAL PERMIT E::] 5 CHANGE OF INFORMATION O 7 PERMANENTL CLOSED SITE/ <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETE <br /> DBA OR FACILITY NAME 1C NAME OF OPE TOR /ni 11 <br /> LJ or <br /> /C� hI? S <br /> ADDRE3 11 OS NEAREST CROSS STREET PARCEL#(OPTIMAL) <br /> CITY NAME 1.� ` �` J STACA ZIP CODE SITE PHONE s WITH AREA CODE <br /> G \TC�✓1 <br /> V Box <br /> TOINDCATE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q OLOCAL--A ENCY Q COUNTYAGENCY' Q STATE-AGENCY' Q FEDERALAGENCY' <br /> N outner of UST M a public agency,corrplele the following:name of Supervisor of division,section,or oNica which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR O RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(gNidW) <br /> FARM Q 4 PROCESSOR IQ 5 OTHER OR TRUST LANDS I nO <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- UST BE COMPLETED D IOS 7-Z� <br /> NAME CARE OF ADDRESS INFORMATION <br /> S� <br /> MAILING OR STREET ADDRESS ✓ bosb6d"as Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> M CORPORATION Q PARTNERSHIP Q CDUNTYAGENCY IQ FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> II <br /> MAILING OR STREET ADDRESS ✓bos bbsficate Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE LP 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) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ bosbintlkab Q i SELF-INSURED [-12 GUARANTEE Q 3 INSURANCE Q e SURETY SONO <br /> 0 6 LETrEROFCREOT Q 6 EXEMPTION Q 0 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be send 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 It SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> C�OUNTY# JURISDICTION# <br /> Nil <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICTOODE - <br /> i <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(3W) FCROD3AAi <br />