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A [ <br /> f�e� C <br /> STATE OF CALIFORNIA ,[ <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD 4.e�� � �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,s <br /> I� COMPLETE THIS FORM FOR EACH FACILRYISITE .a.+`- <br /> MARK ONLY I_.1 1 NEW PERMIT O 3 RENEWAL PERMIT Q 6 CHANCE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM U 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELA(OFnONAU <br /> 4kW`tlV I I—, 49S-SSS <br /> CRY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 417 CA `7,5;32z I <br /> TO INDICATE =CORPORATION O INDIVIDUAL =PARTNERSHIP O LOCAL AGENCY O CWNrY-AGENCY' l�STATE-AGENCY' =FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •Hamer of UST is a public Agenq,con olete the following:name of Supervisor of division,section,or oNlos which operates the UST <br /> TYPE OF BUSINESS O L GAS STATION 0 2 DISTRIBUTOR RESERVATION s OF TANKS AT SITE E.P.A. I.D.&(opVa* <br /> Q 3 FARM H 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT 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 it WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S' V- Go, Aepr <br /> MAILING OR STREET ADDRESS ✓box b Imilut, INDIVIDUAL OLOCAL AGENCY STATEAGENCY <br /> •O. E-D CORPORATION O PARTNERSHIP O COUKrV-AGENCY FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE P NE a WITH AREA CODE <br /> 51 De-le;7 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> • Lei. i /�i- o r= Rx­zVwe_ <br /> NAI RSTREETADDRESSS ✓ bubindeps INDIVIDUAL LOCAL AGENCY STATE-AGENCY <br /> • &/• ao V o J, CORPORATION O PARTNERSHIP COUNTYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME ST 21syj&Zc HONEi WITH`�ACOfDA <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ Wr biMicale E-1 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O I SURETY BOND <br /> O 5 LETTEROFCREDr 6 EXEMPTION 0 m 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: L O I.O 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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION t FACILITY# <br /> LOCATION CODE .OPTIONAL CEN US TRACTS - - <br /> -OPTIONAL SUPVISORDISTRICT CODE OPTIONAL <br /> z .� yZ3 9s <br /> IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFO TON 0 Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3R3) FOROMSART <br />