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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACHFACILRYISITE <br /> O 1 NEW PERMIT O 3 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO <br /> MARK ONLY <br /> ONE REM � 2 IN 4 AMENDED PERMIT 8 TE V SITE CLOSUREall <br /> I. FACILITY/SIT FORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY E ` NAME OF OPERATOR <br /> ADDRESS 7 NEAREST CROSS STREET PARCEL OPrIONAL) <br /> s <br /> CITU NAM STATE ZIP / SITE PHONE WITH ARFA CODE <br /> CA 5 6 <br /> TOIN ICABOX RPORATION INDIVIDUAL =PARTNERSHIP D LOCAL-AGENCY <br /> 1]COUNTY#GENCY' I�STATE AGENCY' O FSDERALAMNCY' <br /> •I owner of UST Is a public agency.co Mowing:none of Supervisor of division,section,or office which operatse the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS Al SI .'A. I.D.#ibP(bM0 <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> �1. EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> 1 DAYS:NAME( T, IRST) PHONE a WITH AREA LADE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NI . NAME(I AST. PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME silt CARE V) RE OR TION <br /> MAILING OR STREET AD RESSe _ loEbaN Q INDIVIDUAL LOCALAGENCY STATE-AGE <br /> V <br /> CORPORATION O PARTNERSHIP 0 CWNTYAGENCY FEODML Y <br /> CITY NAME STATE ZIP CODE / �( P aWIT REA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) b (f <br /> EOF OW R CARE OF ADDRESS INFORMATION <br /> MAILING BEET DflESS ✓box bindNLe INDIVIDUAL (] LOCAL- Y TE-AGENCY <br /> =CORPORATION PARTNERSHIP l= COUNTY-AGE NLY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P H 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 BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eoz aYlacsM I�1 SELF-INSURED O 2 GUARANTEE O a INSURANCE D 4 SURETY BOND <br /> O 5 LETTER OF CREDIT =5 EXEMPTION E�]99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlesvgx I or 11 is C <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I IL In. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,YS!t YS! AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE T EA_ It <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a (/ ` , JURISDICTION a FACILITY IF <br /> F'f <br /> LOCATION OODE -OP NAL CENSUS T T a-OPTIONAL SUPVL90R-DISTRICT CODE -OPTIONAL <br /> /� a <br /> THIS FORM MUST Of 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 /> FaAIXdIAN7 <br /> FORM A ISMS) <br /> �� f�J <br />