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Ifo 1 <br /> /1 C-1 �/ 'STATE OFCAUFORMA << "� <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 5 3 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C�4pryY�- <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT (I TEMPORARY SITE CLOSURE r / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACIL�ITT�Y�^NAME <br /> ,^1 NAMEOFOPERATOR <br /> �F�7/Uf <br /> AD KESS NE EST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP OODE SITE PHONE WITH AREA CODE <br /> G 0CA ZOO <br /> TO DIox <br /> RTE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner d UST Is a public agency,oomplde the lollawing:name of Supervisor division.section,or office which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 0 OR / <br /> 3 FARM 0 4 PROCESSOR 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(�IIIAS FIRST) PHON #WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> GAtiTAXZZ', i�1�7y5 212—Fsz !7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> i <br /> MAILING OR STREET ADDRESS ✓ bcAbindk& Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> - / Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI NAME 5 D STATV ZIP CODE l� ONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓borbindicak Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> QCORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY Nq STA ZIP CODE PHON WITH AREA CODE <br /> 22-Z-Ssz iZ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4—[4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓babMdkate 0 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q 4 SURETYBOND <br /> 0 5 LETrER OF CREDIT Q 6 EXEMPTION Q 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 /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANDc6RRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MOfNTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LCODE -OPT/ONAL LENS STRACTi-OPTIONAL <br /> YfSUPVISOR-DISTRICT CODE -OPIA7NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OTAY, <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • Fpi0033AR7 <br /> • <br />