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STATE OF CALIFORNIA •`� <br /> STATE WATER RESOURCE NTROL BOARD 9° <br /> �NMERGROUND STORAGE TANK ER APPLICATION e FORM A <br /> COMPLETE THIS FO FOR EACH FA <br /> ae, <br /> MARK ONLY 0 t NEW PERMIT ❑ 3 RENEWAL PER T <br /> 6 CH POE OF INFORMATION ❑ 7 pERMA NTLY CLO E <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ / AMENDED PER IT <br /> ❑ 8 ('OflARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADD ESS-(MUST BE CO LET <br /> DBA OR FACILITY NAME/]- <br /> /-/U%I <br /> ADDRESS O /t NAMEOFOPERATOR <br /> (�(��'(� <br /> NEAREST CROSS STREET PARCEL#(OPfpNAW <br /> CITY NAME l <br /> BOX STATE ZIP COD <br /> ✓ ��� 17E PHONE#WITH AREA CODE <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> 'If owner of UST is a public COUNfY-AGENCY' f�g7gTE.gQFEDERAL-AGENCY- <br /> TYPE <br /> complete the following;name of Supervisor of ODISTRICTS' QGENCY• <br /> Nision-sectbn,Of Office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR <br /> E=] 4 PROCESSOR 6 OTHER ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(gNimaq <br /> 3 FARM RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE •gp1IGReI <br /> DAYS: NAME(LAST,FIRSn PHONE a WITH AREA CODE <br /> NIGH73: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS n <br /> PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> CARED ADDRESS INFOflMATION <br /> MAILING OR STREET ADDRESS <br /> ✓boxblMkate Q INDIVIDUAL QLOCAL-AGENCY E:1STATE-AGENCYCRY NAME -- — ---_ Q CORPORATION Q PARTNERSHIP Q COUNrYAGENCY Q FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> FNAMrOFOWN1EH STREET ADDRESS <br /> ✓ boe biMbaN Q INDIVIL Q LOCpLAGENCY— Q CORPORATION Q PARTNERSHIP Q STATE AGENCY <br /> STATE — Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> ZIP CODE PHONE As WITH AgEA CDDE <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 /> ✓boabintlkae Q I SELFINSURED Q 2 GUARANTEE Q 9 LET ER OF CgEDT Q S GUARA TE 0 3 INSURANCE Q 4 SURETY BOND <br /> EXEMPQ 99 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.❑ II. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'S TITLE CORRECT <br /> MONTW /YEAR <br /> LOCAL AGENCY USE ONLY <br /> COON # J q 2 JURISDICTION NId <br /> f ,—�—T� FACILITY# <br /> LOCATION CODE -OP NAL CENS S 7 C I I��I JI <br /> NAL SU ISO -0 TR CODE -OP77ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS CHANGE OF SRF MATION ONLY. <br /> FORM A p93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE GULATIONS <br /> • FORDM3A R7 <br />