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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT �I����ycL`6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ s AMENDED PERMIT u B TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME OF OPERATOR <br /> Tq <br /> A� , - )1 (, �`/��/ - NEAREST CROSS STREET PARCEL 0(OPrgNAL) <br /> Rd I <br /> CITY NAME STATE Zip 91 PHON s WITH AREA 8 <br /> CA C/1 <br /> T NDICA CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 1:3 COUNTY-AGENCYSTATE-AGENCY' O F®ERALAGENCY' <br /> If oener d UST Is a pubic agency,corrvie the folloaA name d S DISTPoCTS' <br /> rp: Supervisor d dNbbn,eeclbn,or dliw which operates the UST <br /> TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN *OF TANKS AT SITE E.P.A. I.D.i iddlooal) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIRST) PHON i WITH AREA DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> 20 3 3�t <br /> NI <br /> S. NA E AS(L T,FIR - PHON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> e1._33 TF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME c CAREOFADDRE$4 INFORMATION <br /> MAILI OR STR T DR SS �^ L n ✓EubMAcYs INDIVIDUAL �LOCAL-AGENCY 0 STATE.AGENCY <br /> ) l/ `,w�Vp{/L� O CORPORATION O PARTNERSHIP O COUNITYAGENCY O FEDEML-AWNCY <br /> CITY NA=DD . s-�s'A/I�r-'s-� s �� STATE <br /> TG ZIP ,� P NE#OTHAREA2 +,.,^ <br /> ff <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ��"S3ST Opel .�.J( <br /> NAMEOF OWNER �A ' CARE OF ADDRESS INFORMATION <br /> ter/ <br /> MAILING OR STREET ADDRESS A"+ ✓ bombing's' INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> V CORPORATION O PARTNEASHP O CWNrYAGENCY O FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO 14141-Iylni� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bb No Indices, 1 SELFINSURED 2 GUARANTEE D 3 INSURANCE O A SURETYBONO <br /> 5 LETTEROFCREDIT Q 6 EXEMPTION L—I 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: I.❑ IIIT.❑ <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 A SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Tr FACILITY ar _vt' � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT-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 INFORMATK)N ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) FaRam3tAT <br />