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STATE OFCALIFORMA �� <br /> STATE WATER RESOURCES CONTROL BOARD i , <br /> xA �( UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ��L� <br /> COMPLETE THIS FORM FOR <br /> EACH FACILITY/SITE •' ,,,, �,,, ' <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT UCI 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSE <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT ~0 6 TEMPORARY SITE CLOSURE r <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS•(MUST BE COMPLETED) <br /> DBA OR CI PTY NAME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> 3CA <br /> 9/110 REET PARCELa(OPrONAU <br /> CITY D <br /> SITE PHONE WITH AREA CODE <br /> ✓ Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAI-AGENCY Q COUNTY#GENCY' Q STATE-AGENCY' <br /> If Amer d UST Is a public agency,cceplete the Iollowi DGTPoCTS' Q FEDERAL-AGENCY'name d Superv4ar of d'rvbbn,cectbn,or orrice which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION O 2 DISTRIBUTOR IQ ✓ IF INDIAN a:I TANKS AT SITE E.P.A. I.D. NMAanaq <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE a ITH AREA CODE AY NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHII NAME(LAST,FIRST) PHONE P WITH A14i CODE r NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Sf CARE OF ADDRESS INFORMATION <br /> ,eVe cz se <br /> MAILING.CB STREET ADOWS v, Ew bbticYa Q INDIVIDUAL Q Q LOCAL-AGENCY STATE-AGENCY <br /> 1y 0 CORPORATION Q PARTNERSHIP Q COUNINAGENCY Q FEOEMLAGENCY <br /> CITU NAME ST <br /> ZIPQODE PHONE aVJITHAREACCIDE <br /> s - 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Esr birdimla Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL#GENCY <br /> CITY NAME STATE 21P 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bow bydbay Q f SELF-INSURED IQ 2 GUARANTEE S INSURANCE Q 4 SUflETY BDNp <br /> Q 5 RETTEROFCREDIT Q 6 EXEMPTION OTNEfl <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ISI is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E ILK 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(PRINTED b SIGNED) OWNER'S TITLE DATE MONTHIDAYrYEAR <br /> LOCAL AGENCY USE ONLY !t <br /> 211 <br /> COUNTY i JURISDICTION♦ ILrTY i <br /> 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OP SUPVISOR-'O RIOT CsODE -OPTIONAL <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 /> /F/O}RM A(393) O <br /> / V I� Ae � � 11•Y� FOROOI�A.Ri <br /> (^=1, �a � �� til LJ <br />