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60UR <br /> we <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD "�s' �;g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A fi . <br /> COMPLETE THIS FORM FOR EACH FACILt1'YrSITE <br /> 1 NEW PERMIT � 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE ITEM 2 INTERIM PERMIT <br /> q AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED)ME OF <br /> OPERATOR <br /> OSA OA_FACILITY NAME — <br /> -7—C.T i/ %fi' Ur] � " - PARCEL#(OPTIONAL) <br /> NEAREST CROSS STREET <br /> ADDRESSAA _ <br /> STATE ZIP CODE SITE PHONE#WITH AREA COOS <br /> CITY NAME CA <br /> ] <br /> LOCAL-AGENCY COUNTY-AGENCYSTATE•AGENCY' [] FEDERAL•AGENCY' <br /> `/ BOX CORPORATION � INDIVIDUAL PARTNFRSHIP <br /> 70 INDICATE DISTRICTS, <br /> 11 owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> ✓ IF INDIAN #OF TANKS AT SITE <br /> TYPE OF BUSINESS 1 GAS STATION � 2 DISTRIBUTOR 0 RESERVATION <br /> �] 3 FARM �_ a PROCESSOR = 5 OT1#ER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optian;31 <br /> PHONE#WIT AREA CGDE DAYS: NAME(LAST,FIRSTS <br /> PHONE#WITH AREA CODE <br /> DAYS: rr��ME OAST,FIRST) r <br /> PHONE#WITH AREA COOS NIGHTS: NAME(LAST.FIRST) <br /> PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) <br /> it. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAS arm �' 7 � J ,/ bozgindVcale INDIVIDUAL LOCAL-AGENCY [] STATE-AGENCY <br /> MAILING OR STREET DDRESS <br /> CORPORATION PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ taxbVndcale 0 <br /> INDIVIDUAL ® LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION PARTNERSHIP = COUNTY-AGENCY l__1 FEDERAL-AGENCY <br /> STAT, ZIP CODE <br /> �PHONE�#l �CODE <br /> CITY NAME c i- r i.t <br /> T�> <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-1-4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> l� 1 SELF-INSURED O 2 GUARANTEE a 3 INSURANCE 0 4 SURETY BOND <br /> ✓ txMbindkats Q 5 LETTEROFCR€DIT 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: <br /> L M 1l.E] III.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER.WURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&S4GNED) <br /> OWNER'STITLE DATE MONTWDAYlYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION# FAC1L[TY# <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS •OPTIONAL SUPVISDR-DISTRICT CODE -OPTIONAL <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 REGULATIONS FOR0033A-R7 <br /> FORM A(3193) <br />