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a <br /> RNIA <br /> R RE OURCES CONSTATE WATER RESOURCES CONTflOL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACIL <br /> MARK ONLY D I NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED S1TE <br /> ONE ITEM F72 INTERIM PERMIT 4 AMENDED PERMIT a S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> vti�„ ss I � SC_ ILoe <br /> ADDRES�S/� y � (//� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> -�/ Y �� !/IV/4 C/ 0 <br /> CITY NAME/ / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ABox <br /> Z� <br /> TO INDICATE O CORPORATION �INDIVIDUAL l�PARTNERSHIP LOCAL <br /> DISTRITSENCY 0 COUNTY-AGENCY' D STATE-AGENCY' O FEDERALAGENCY' <br /> N Avner of UST a a Public aaencY,oortglete the flna ne of SUP6rv50,of divas aectlon, ice which operatec the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS ATSITE E.P.A. 1.D.a(optimal) <br /> RESERVATION <br /> 0 9 FARM 4 PROCESS <br /> OR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE It 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 a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> SI- Q„ 3 N Sc(,ta8>I <br /> MAILING OR STREET ADboxRESS ✓box a htli:a = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> . D. A-J JC Z O CORPORATION = PARTNERSHIP O COUNTY-AGENCY D FEDERAL AGENCY <br /> CITY NAME STATE ZIP CO E PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION:(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 04.7 <br /> MAILING OR STREET ADDRESS ✓but Mica 0 INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> O <br /> CORPORATION D PARTNERSHIP COUNTYAWNCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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(S) USED <br /> ✓bp4 py#Wy I�i SELF-INSURED 2 GUARANTEEHANCE I�4 SURETY <br /> D 5 LETTEROFCRED3INST D 6 EXEMPTION CTHER <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. 111. <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(PR INTED B S IGNED) OWNER'S TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• <br /> ® 0 <br /> �' ATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �z f: <br /> 2 <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 /> FORM A 1393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATpNS °�`m <br />