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a STATE OF CALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILrTY/SITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED <br /> ONE REM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC TY NAME NAMEOFOPERATOR <br /> G,� 7d i Y <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> - - dA�4 <br /> CITY NAM[ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �� CA <br /> T NDIox <br /> RTE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY =3 COUNTY AGENCYO STATE-AGENCY' O FEDERAL AGENCY' <br /> If canner of UST Is a public agency,epnpm <br /> lele the lollowlnp:nae of Supervisor of division. DISTRICTS'n,section,or of ca which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIANNDS #OFT KS AT SITE E.P.A. I.D.#ppi na# <br /> RESERVATION <br /> O 3 FARM 0 4 PROCESSOR 5 OTHER OR RESERVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFOR ATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDR S ^ ✓ boxblMkab INDIVIDUAL I� LOCAL-AGENCY STATE AGENCY <br /> /051 v�G�� �Z�- CORPORATION O PARTNERSHIP E::] COUNTY AGENCY FEDERALAGENCY <br /> CITY NA STA ZIP CODE PHONE# ITH A EA COD <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF v CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL I= LOCAL AGENCY E]STATE-AGENCY <br /> CORPORATION PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL AGENCY <br /> STATF, ZIPHONE A AT I AREA C <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB` -- <br /> EER I Call(916)322-9669 if quesGonsvarise. <br /> t/= <br /> TY(TK) HO 4 4- -l l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box Is,Indicate 0 1 SELF-INSURED E-1 2 GUARANTEE 3 INSURANCE =1 4 SUREN BONG <br /> 0 5 LETTER OF CREDIT l=6 EXEMPTION 999 OTHER U• - <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: L[7] 11. III.a <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If FACILNY• r- <br /> MI o 5 iz�o y <br /> LOCAGTI.ON CODE -OPTIONAL CENSUS3RACTs -OPTIONALSUPVISOR-DISTRICT CODE -OP7pNAl. <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 /> FORM A(393) <br /> OWNER MUST FILE THIS FORM WTM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAr"m <br /> IAV <br />