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1 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W.,� �, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A • �, ;e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °•t�•aa"'•. <br /> MARK ONLY O f NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION EV 7 PERMANENTLY CLOSE SITE <br /> ONE rTEM Q 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB -FACILITY AM �a NAME FOPERATOR �+ <br /> 1tl Q J I <br /> AODRE$ - NEA TC OSS ST ETA / PMCELCOPTIONAW <br /> lot I <br /> CITU N" <br /> STATE ZIP D vV PJ SITE PHON •WITH AREA CODE <br /> CA 68- <br /> T NDCRTE D CORPORATION 0 INDIVIDUAL E3 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' D STATE-AGENCY• FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If Owner Of UST to a public agency,complete the following:name of Supervisor of division,section,or Once which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IN OF TI�KSAT 317E E.P.A. 1.D.#(aplwnaQ <br /> RESERVATION <br /> / IFINDIAN � J� <br /> 3 FARM Q 4 PROCESSOR 0 5 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#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmblrbiab INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP D COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME r w <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bcrbindiww Q INDIVIDUAL Q LOCAL AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION <br /> T,UST <br /> �STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box to Indicate t SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D s LETrEROFCREDIT 0 6 EXEMPTION O W OTHER <br /> VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.D II. Ili. <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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> UPVISOR-DI5 -ONALLOCATION E-OPTIONAL CENSUS TRACT# -OPTICym <br /> 60 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESSTH IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE EGULATIONS <br /> FORM A(3193) 0 <br /> - 1 <br /> FOR0013AA7 <br />