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p6�e <br /> STATE OF CALIFORWA �"� �'� <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ee <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> ORA OR FACT ITY NAME NAME OF OPERATOR <br /> G/ ueo� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> r-- G <br /> CITY NAME STATE ZIP CODE SIM PHO #WITH AREA CODE <br /> CA 9rZv 6vif 5— 59 O <br /> TO DIox <br /> RTE CORPORATION O INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O SrATE.AGENCY' O FEDERAL-AGENCY' <br /> DSTRICTS' <br /> 'ff xavner d UST Is a public agency,complete the following:nann,of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN IN OF TANq AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUSTVATION LANOS _ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME( ST,FIRST) PHOpE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONK#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ./ ✓box bindkaU lzINDIVIDUAL 0 LOCAL-AGENCY EJ STATE-AGENCY <br /> 11z0 5 CORPORATION =-PARTNERSHIP ED COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME '^ STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OFOW R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindkaN INDIVIDUAL O LOCAL AGENCY D STATE-AGENCY <br /> R - Q-�� ��D ORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME,,/, <br /> `VN9TA ZIP CODE PHONE#WITH AREA CODE <br /> 0/O — Z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 - o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindkate SELF-INSURED O 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 1 5 1ETTER OF CREDIT O 6 EXEMPTION O BB 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.EJIII. <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 MONTH7DAVIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 9 iy <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF INFORMA ON ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOt10033AA7 <br /> 0 <br />