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a <br /> STATE OF CALIFORNIA ' ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD ;�+ aA e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITIE °"'O""�- <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERMANENTLY CLO <br /> SED SITE <br /> ONE ITEM O 2 INTERIM PERMIT E-] a AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME D NAME OF OERAOR EL$r( <br /> OPTONy <br /> ADDRESS NEAREST STREETROSS <br /> CITY NAME STATE ZIP SITE PHON $WITH AREA CODE <br /> CA <br /> T 11 Box oxTE O CORPORATION D INDIVIDUAL �PARTNERSHIP LDCAL-AGENCY 0 COUNTYAGENCY• O STATE-AGENCY' 0 FEDERAL-WENCY' <br /> � ( DISTRICTS' <br /> •M owner d UST la a Public aeerlcy,complete the fobowinp:name of Supervisor of dNbbn.seQbn,IX oNioe which opxNae the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION $OF TANKS AT SITE E.P.A. I.D.$(nprwW) <br /> 3 FARM O A PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYftNAAMME(LAST.FIRST) P E N IH^ARE CDOE Y3: NAM (LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: (LAST,FIRST) PHONE A WITH AR CODE ..— NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME YS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boxbMIcale (] INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPORATION D PARTNERSHIP COUNTYAGENCY [:1 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER,L-C/Y rw CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREET ADDRESS ✓ boxb1MV INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> O CORPORATION D PARTNERSHIP COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE$WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 i1 questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkaN E=1 i SELF-INSURED GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> O 5 LETTEROFCREDIT MPnON 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.IXI II.[—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISTRUEE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERSTIRE DATE MONTHOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 0 ILrrY 0 <br /> L <br /> LOCATIOn OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT -CIP11ONAL <br /> D <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 /> FORMA(393) FOROWOAA] <br />