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STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A , ;e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERATOR <br /> Wt <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPfIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CAv If <br /> S 20 <br /> TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY E:J COUNTY AGENCY• E-D STATE-AGENCY' ED FEDERAL AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,conplele the following:name of Supervisor of di0sbn,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OF TANKS AT SITE I E.P.A. 1.D.a f0pricnal) <br /> E:] 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME ILAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> SISKIq <br /> MAILING OR STREET ADDRESS ✓ box blMkate INDIVIDUAL LOCAbAGENCY O STATE AGENCY <br /> (]CORPORATION 0 PARTNERSHIP O COUNTY AGENCY � FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binAkma = INDIVIDUAL l� LOCAL I� STATE AGENCY <br /> lD CORPORATION O PARTNERSHIP COUNTY AGENCY 0 FEDERAL <br /> CITY NA STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - $ g <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindkaU t SELF INSURED Q 2 GUARANTEE E-3 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT Q 6 EXEMPTION E::] 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. II.❑ 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'S TITLE DATE MONTWOAYrYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® U�" D 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SIPVISOR-DISTRICT CODE -OPT70NAL <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(3183) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM <br /> F0110037AA7 <br />