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'V6OV- C <br /> STATEOFCAUFORISA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , nj <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE oR+" <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Da 1KZAAL CA <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFFONAL) <br /> 7 L J +-o F' <br /> CITY NAME STATE ZIP CODE SI PHONE#WITH AREA CODE <br /> ¢, o CA 953 z0 <br /> It <br /> TOINDICATE O CORPORATION E::] INDIVIDUAL Q PARTNERSHIP LOCALAGENCY 0 COUNTY-AGENCY' E_—] STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'N owner of UST Is a public agency,cc rplete the following:name W Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(opNmaQ <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) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> i .2Q <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Is R d <br /> MAILINGORSTREET ADDRESS ✓boxblydicaf# INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P ) � O CORPORATION (] PARTNERSHIP Q COUNrY-AGENCY O FEDERAL-AGENCY <br /> CI NAME STATEZI CODE PHONE#WITH AREA CODE <br /> Cf� 53� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILIN RSTREET ADDRESS ✓ bMbirdcal, INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> NN\ O CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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- - Q S $ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> FEE <br /> boric Mkate = 1 SELF-INSURED D 2 GUARANTEE D 3 INSURANCE O A SURETY BOND <br /> FEE <br /> D 5 LETrER OF CREDIT O 6 EXEMFRON 99 OTHER <br /> V1. 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 Il.❑ 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) OWNERS TITLE DATE MOrNTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® R!Vm Db / <br /> LOCATION CODE •OPTIONAL CENSUS TRACTi -OPTIONAL9lNWL40R-DLSTRICT CODE -OPTpNAL <br /> Z — 7 <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 REGULATIONS <br /> FORM A(393) 0 <br /> 0 <br /> FOR0033AR7 <br />