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STATEOFCAUFORMA ,• '� <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FqldllISITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION Q 7 PERMANENTLY <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM ::pS NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTKNlAU <br /> CITY NAME STATE.1 Box 21P CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCy- D STATE-AGENCY' D FEDEM4AGENCV' <br /> DISTRICTS' <br /> N owner b UST is a public agency,oomplela Use folowing:name of Supervisor of dNbbn,section,w oaite which operates the UST <br /> TYPE OF BUSINESS O i GAS STATION ED 2 DISTRIBUTORQ ✓ IF INDIAN N OF TANKS AT SITE E.P.A 1.D.N(opYAv) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 0 5 0114ER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)"optional <br /> DAYS:NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> NK3HTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRE ✓ boxbXlAcw <br /> ED INDIVIDUAL LOCAL-AGENCY O STALE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O AGENCY O FEDERALAGENCV <br /> CITY NAME STATE ZIP CODE PHONE TN AREA CODE <br /> III. ANK OWNER INFORMATION- MUST BE 0 LETED) <br /> NA OF EH I CARE OF ADDRESS INFORMATION <br /> MAIL OR STREET DRESS ✓bos"dtais 0 INDIVIDUAL LOCAL-AGENCY OSTATE-AGENCY <br /> ) /� CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDEML-AGENCY <br /> CITY NAME',,,,., ST ZIP PHONENWIT AREA CODE <br /> IV.BOARD OF EO N UST STORAGE FE ACCOUNT NUMBER-Call(916)322-9669 if quest Ise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hM bbdiu0s t SELF INSURED O 2 GUARANTEE O 3 INSURANCE O ETY BOND <br /> 5 IETTEROFCREDIT D a ExEMPTION O Sa OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I is chelated. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D I. II <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IST AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERSTITLE RATE MONTH/DAYNRAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY• <br /> 1 v <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPV OR-DISTRICT CODE -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 /> FORM A(3931 .// Y' FOR9W3AA7 <br />