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�eW° Pf <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> _ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> y COMPLETE THIS FORM FOR EACH FACILIrY/SITE <br /> MARK ONLY F-1 I NEW PERMIT Q 3 RENEWAL PERMIT I] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1TE <br /> ONE REM I] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 g TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> F / <br /> A DflESs NEAREST CROSS STREET PARCELM(OPfK1NAq <br /> CITY NAME STATE ZIP CODE SITE PHONES WITH AREA CO DE <br /> ArA&IOCA GllZo <br /> T NDIIC TE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNrY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> II owner of UST Is a public agency,complete the To9owln :name of S 06TPJCTS- <br /> g upervkor o/tlNkbn,section,or office which operalm the UST <br /> TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS ATSITE E.P.A. I.D.#(gNban#) <br /> 3 FARM 4 PROCESSOR 5 OTHER a RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIM Y) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 71 <br /> NIGHTS: NAME(LAST,FIRST) PHONE AREA CODE NIGHTS:NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> E <br /> MAILING OR STREET ADDRE ���j �7� ✓ hot biMkals L-1INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> v V G�� O CORPORATION ED PARTNERSHIP 0 COUNfY#GENCY Il FEDERAL#GENCY <br /> CITY NAME` G/� STATE ZIP CODE P ONE# ITH AREA CODE <br /> 9 /Z Z D7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING OR STREET ADDRESS ✓bwbindkak E:) INDIVIDUAL O LOCAL-AGENCY 0 STATE- <br /> AGENCY <br /> / _ I�CORPORATION = PARTNERSHIP =COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> (� 9� �� .ITH AREA COD <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER°Call(916)322-9669 if questions arise.. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ <br /> box bintlkaN O t SELF-INSURED =2 GUARANTEE 3 INSURANCE <br /> A SUflE V BOND <br /> O 5 IETTEq OFCflEOR =S EXEMPTION OTHER Lz. OE <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.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS 1m # -Q^TIONAL 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 INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG <br /> FORM A(393) • FOROD33A R7 <br /> 1� h <br />