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• • coo^ rA <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A m� <br /> COMPLETE THIS FORM FOR EACH FACILITYSITE <br /> MARK ONLY D t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S <br /> ONE REM E:1 2 INTERIM PERMIT 0 4 AMENDED PERMIT [:] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nPA OR FACILITY NAME NA OF OPERATOR <br /> ADDRESS NEAREST CROSS ST TPARCEL#(OPTIONAL) <br /> 3 <br /> CITU ME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOINDICATE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY E-1 COUNTY-AGENCY' O STATE-AGENCY• O FEDERAL-AGENCY' <br /> N owner of UST Is a public agency,complete the following:narre of Superviecr of tlNDISTRICTS' <br /> ic!on,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR0 ✓RE./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optioonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c yJ - <br /> NIGHTS: NAME(LAST,FIRST) PRIBNE#INIIHAREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA E CARE OF ADDRESS INFORMATION <br /> �MAItIa <br /> MAILING OR STREET ADDRESS ✓ bosblMkab INOIVIDUAI D LOCA4AGENCY D STATE-AGENCY <br /> CORPORATION O PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> i CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> C-46, qix—a3 4P <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> N E:OWNERCARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hoe to iMicate 0INDIVIDUAL 0 LOCALAGENCY 0 STATE-AGENCY <br /> t Peg Alt No CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SgN .�ixr FTv-(c0 <br /> IV. BOAAD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions-arise— <br /> TY <br /> riseTY(TK) HQ 4 4- - U I LJ L1 I u L� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0indicate 0 I SELF-INSURED L-1 2 GUARANTEE 0 ] INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT O 6 EXEMPTION 0 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: 1.0 II. III. <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 a SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# <br /> Sze l 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 8 y� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS 1S A CHAN E OF SITE iNFOMATION ONLY. <br /> OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3r93) FOg00011i1T <br />