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STATE OF CALIFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD e`y ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� m° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'tl <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Rf'5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIU NAME ' NAME OF OPERATOR <br /> FACT <br /> ADDRESS- NEAREST CROSS STREET PAPCEL#(OPnONALI <br /> CITY NSA/MM�,E STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX Q CORPORATION O INDIVIDUAL Q PARTNERSHIP (] LOCAL-AGENCY a COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'IIO'MIBI OI ubI Na Public agewy,fMVievie ft 109]wh;1101118 d 61pamsor 01 division.Section 0r Office W idl operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REIF INDIAN <br /> #OF TANKS AT SITE E.P.A. 1.D.#W00na0 <br /> ❑ ATION <br /> 3 FARM ❑ # PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bcy 12F��"- Q IKOWDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <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 /> MAILING OR STREET ADDRESS ✓ be,l0 mmte O INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> =CORPORATION D PARTNERSHIP Q COUNTY-AGENCY O 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) HQ M44- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD($) USED <br /> ✓W.10 iWd e 0 T SELF-INSURED I1 2 GUARANTEE O 3 INSURANCE ED 4 SURETY BOND =5 LETTEROFCREDIT = 8 EXEMPTION =7 STATE FUND <br /> O8STATE FIND&CHIEF FINANCIAL OFFICER LEITER O9STATE FUND&CERTIFICATE OFDEPOSIT O10LOCAL GOVT.MECHANISM = 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: 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 /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTW'DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a 9 qG <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 FOR,,,,M THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(,.,,STORAGE TANK REGULATIONS <br /> FORMA(&95) <br />