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i <br /> `P PEepyM f <br /> STATE OFCALIFORMA _ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `^�fof•" <br /> MARK ONLY F-1 f NEW PERMIT 3 RENEWAL PERMIT 0 a CHANGE OF INFORMATION 7 MANENTLY CLOSED SIT <br /> ONE ITEM Q 2 INTERIM PERMIT O A AMENDED PERMIT Q e TEMPORARY SITE CLOSURE SQ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF I AM NAMEOFOPERATOR <br /> ADDRESS ST <br /> ROSS STREET PARCELa(OPTMINAU <br /> IT <br /> CITY NxE7= STATE ZIP SITE a WITH AREA 000E <br /> CA <br /> T NDICATE CD cORpORArm D INDIVIDUAL O PARTNERSISP COUNrYAGEWY' O STATE-AGENCY' O FEDERALAGENCY' <br /> •N owner d UST Is a pubic agency,oorrplde the following:name of Supemew of division.eadbn,or office which operates the UST <br /> TYPE OF BUSINESS O f GAS STATION Q 2 DISTRIBUTOR RE9EIRVATDION a OF TANKS AT SITE E.P.A 1.D.is(OMAN" <br /> 3 FARM A PROCESSOR D] 5 OTHER OR TRUST LANDS C <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST( PHONE a WITH AREA CODE <br /> Z <br /> NIGHTS: NAME(LAST PHONE WITH AREA CODE NIGHT'S:NAME(LAST,FIRST) PHONEa WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INF RMATION <br /> MAILING OR STREET AIDDRESS ✓ascb Q INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> E =CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE P NE a WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING O ETADDRESS ✓box bindbate INDIVIDUAL O LOCAL-AGENCY Q SrATE-AGENCY <br /> Q CORPORATION O PARTNERSMP O COUNTY AGENCY O FEDERALAGENCY <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 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓hosbYduW r�rl SELFINSURED O 2 GUARANTEE D INSURANCE O s SURETY BOND <br /> 5 LETTEROFCREDIT O S EXEMPTION O Ia 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.[::] II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION• FACILITY If <br /> ® Df R4 <br /> LOCATION COD - TIONAL CENSUS TRACT# -OPTIONAL SIPVISOR-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 /> FORMA(393) OWNER MUST FILE THIS FORM WIT-`THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FGRamzwHn <br /> •1t �- <br />