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\ I I Iii i I i <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A z <br /> '�I,IOnM'I <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY L <br /> ONE REM 2 INTERIM PERMIT 0 A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)AME of wETuroR <br /> I MA OR FACILITY NPA!E 07F <br /> ^' -- N ARESTCROSS STREET _ PARCEL A(OPTIONw <br /> AD�DRESS C � /,/��,,,�,. tNlll7` <br /> 'FJ `•�.1F,ySTATE ZIP �� SITE o WITH AREA CODEy <br /> CITY NAME <br /> ✓BD% �CORPoMTION O INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY#GENCY' STATE-AGENCY' FFDEML#GENCY' <br /> TOINOCATE DISTRICTS' <br /> I own,d UST is a public agenry.uunpleta the following:name of SupwiBor of&ision,,action,or office which operates the UST <br /> TYPE OF BUSINESS Q I GAS STATION QF-� 2 DISTRIBUTOR O RESERVATION a OF TANK T SITE E.P.A I.D.A(optlonap <br /> Q 3 FARM EX 4 PROCESSOR Q 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AEEADEOAVS:NAME(LAST.FIRST) NIGHTS: NAME(LASTT..FIIRSST) PHONE,WITH DE <br /> PHONE a WITH ARE'LADE 6 Q 2� ,i M <br /> IGHTS:NAME(LAST.FIRST n 2 O�7 T4 <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> V ✓boxIDW&N 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILINGO <br /> Is <br /> ADDRESS CORPORATION O PARTNEASMP O CWNTV#GENCY 0FEDERAL-AGENCY <br /> F _ O STATE ZIP CODE <br /> PHONE a WITH AREA CODE <br /> i �,TvvY NAME 4�,L, IA` Ai Z <br /> je 4Ajftt. <br /> III. TANK OWNER INFORMAI ION•(MUST BE COMPLETED) CARE OF 4DCPESS ON <br /> NA <br /> I <br /> ✓ bm Indleaw 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ORT ADDRESS COflPoRATION O PARTNERSHIP 0 COUNfYAGENCY 0 FEDERAL#GENCY <br /> LP CO `� PHONEA WRHy CAGE <br /> I�T�A`. !J. IS <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 K- <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> i SELF-INSURED 0 2 GUARANTEE O 7 INSURANCE D A SURETY BOND <br /> ✓bw bYMNwe O 5 LETTER OF CflED1T 0 6 EXEMPTION 0 w 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: <br /> I.O 11.0 III. / <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS TITLE/ DATE 1MONTH'DAYNEAR <br /> OWNERS NAME <br /> �(PRINTED 831GNED) G(.iJl�• Z—T iG <br /> LOCAL AGENCY USE ONLY <br /> I COUNTY p <br /> JURISDICT • °'✓r 3 Y <br /> NT ICT CO - <br /> LOCATION -OPTIONAL CENSUS TpACTi - iK1NAL SUPVISOR-DISDE OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOR B,UNLESS THIS LS A CHANGE OF SITE INFORMATION Of�'. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) <br /> � �E <br />