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STATEOFCAUPORWA ,� '� <br /> STATE WATER RESOURCES CONTROL BOARD +„�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `Niro#"" <br /> MARK ONLY O 3 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED S <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nPA OR FACILITY NAME NA OF OPERATOR11 <br /> ADDRESi� TJ IG \E I r NEAREST CROSS ST T � PARCEL#(OPTIONAL) <br /> CITV33ME F STATE ZIP LCODE SITE PHONE/WITH AREA CODE <br /> CA <br /> TOINDICATE =CORPORATION IN0IVIDUAL =PARTNERSHIP = LOCAL AGENCY =COUNTY AGENCY = STATE AGENCY' = FEDEMLAGENCY' <br /> DSTRICT9' <br /> II owner or UST Is a public agency.cerrplete the following:name of Suporvlaor of d"lon,/action,or office which operate/the UST <br /> TYPE OF BUSINESS = 1 GAS STATION = 2 DISTRIBUTORgESERVATOION 4O TANKS AT SITE E.P.A. I.D./(cptlona/) <br /> O 3 FARM Q 4 PROCESSOR = 6 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE/WITH AREA CODE DAYS: NAME(LAST,FIRST) - PHONE/,YYIYN AREA CODE <br /> � E4 E (a� - <br /> NIGHTS: NAME(LAST,FIRST) PheNE/VQITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE/WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA E CARE OF ADDRESS INFORMATION <br /> MAI�LTNG OR ST� S t ✓ box blydicaN C] INDIVIDUAL O LOCAL 0 STATE AGENCY <br /> _.`l,a2. _C ( rGeN Q Q,4 I�CORPORATION = PARTNERSHIP Cj COUNTYAGENCY � FEDERAL#GE Y <br /> CITY NAME STAATEE ZIP <br /> CODE PHONE/WITH AREA CODE <br /> V ` <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> N EDF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa Is Indica = INDIVIDUAL = LOCAL AGENCY =STATE AGENCY <br /> _2-f 2 CG LI j =CORPORATION O PARTNERSHIP =COUNTYAGENCY = FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE/WITH AREA CODE <br /> IV.BOAAD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 If questions arise. <br /> TY(TK) HID M44- b <br /> - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bleEkab = I SELF INSURED =2 GUARANTEE = 3INSURANCE =A SURETY BOND <br /> =5 LETTEROFCREOR =9 EXEMPTION = W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O 11. III.a I <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 TI rLE DATE MONTWDAYNEIR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY# 0,7.5191/e <br /> F9T9_1 g z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHIN E OF SITE IIF MATION ONLY. <br /> OWNER MUST FILE THIS F01r,THE LOCAL AGENCY IMPLEMENTING THE UNDERG D STORAGE TANK REGULATIONS <br /> FORM A(M) - FOROWSAN7 <br />