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t60UN ! <br /> STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC 2N NAIP�� NAME OF OPERATOR <br /> ADDRESS�Do/ /�OA A NEAREST CROSS S PARCEL M(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> o/ CA <br /> '/ BOX <br /> TO INDICATE F__1 LOCAL-AGENCY CORPORATION INDIVIDUAL = PARTNERSHIP 0 DISTRICTS' COUNTY-AGENCY' 0 STATE-AGENCY' ED FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS = 1 GAS STATION 0 2 DISTRIBUTOR RESERVATIONIF INDAN N <br /> #OF TAKS AT SITE E.P.A. I.D.#(optional) <br /> (!S� FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NA r�E(LAST, IRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ��3!5�-;5/3F _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMCARE OF ADDRESS INFORMATION <br /> o MveA -77,P,��7 <br /> MAILING OR STREET ADDRE S ✓ box to Indicate = INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> loo Qr 0-1 CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE, ZIP CODE PHONE#WITH AREA CODE <br /> Lo�-r - � OVD <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OVjNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDR SS /� ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> ?Q b <br /> ( �Q� ! J �Oq/� CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHON #WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -[71 �- A-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate U 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =6 EXEMPTION 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: I.F7 H. III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND COR ECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> oZ z3- Z� c <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 REGULATKNiV�4?4, <br /> FORM A(3193) 0033A43 W11 1, R7 <br /> / / <br />