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STATEOFCAUFORNIA ,[ "; <br /> STATE WATER RESOURCES CONTROL BOARD UNDERGROUND <br /> ear o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A O O , 1 ;s <br /> / COMPLETE THIS FORM FOR EACH FACILRYISITE °a�[caw" <br /> \/I MARK ONLY I/ t NEW PERMIT 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NA OFOPERATOR <br /> I 5L-1ZU fC = O/V — I --L) � <br /> N <br /> ADDRESSNEAREST CROSS STREET PAi(OP <br /> _ fpNAU <br /> CI7YNAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> cA I qS v <br /> TO INDICATE RPORATKIN D INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner ot UST Is a public agency.complete the following:name of Supervisor of diwieiun,section,or oNlos which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORQ .1IF INDIAN #OF TANKS ATSITE E.P.A. I.D.#(cpNonal) <br /> ESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER ORTRUS7 LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> AVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 7 DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 174 <br /> IL <br /> IGHTS: NAME(LAST,FIRST) HON Ill AREA DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e�P <br /> 12M <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> � <br /> 4, ^ CARE OF ADDRESS INFORMATION <br /> N y <br /> MAILING OR�STREETADADDRESS fC� �P/T ✓ boxbindi:0 0 INDIVIDUAL O LOCAL-AGENCY [=l STATE-AGENCY <br /> 1 > Q - Rt>, Sums 9oc) ORPORATION = PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITYAAME STT�TEa ZIP CODE PHONE#WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS c ✓ DD fund m INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> J O RD J QQ PORATION 0 PARTNERSHIP M COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STAN ZIP CODEC 1 PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBCC/ER-Call(916)32296669Ciff questions arise. <br /> TY(TK) HQ F41-4]- <br /> V. PETROLEUM UST FINANCIAL R PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0lWicaN SELF-INSURED =2 GUARANTEE 3 INSURANCE O A SURETY BOND <br /> =5 LETTEROFCREDIT 0 6 EXEMPTION D gB 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: I.F1 IL 1pl�III. <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&SIGNED) OWNER'STfRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDCTION# FACILITY If <br /> m <br /> LOCATION CODE-OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-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 REGULATKW <br /> FORM A(3"93) . � FOR69131A7 <br />