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a • <br /> STATEOFCALIFORNIA �� ''� <br /> STATE WATER RESOURCES CONTROL BOARD 3�, v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e� i <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE � `a�.o.w�' <br /> MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q # AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE \. ! <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Da rL1 mache?e4 <br /> ADDRESS I ^ _j NEAREST CROS&STREET PARCEL#(OFfIONAU <br /> Vd4Z <br /> CIN NAME STAZIP CODE TEP NE#WWJF AREACYIIE <br /> I/ BOX TE <br /> TOINgCATE RIORATKN O INDIVIDUAL O PARTNERSHIP LOCAL AGENCY UMYAGENCYSTATE-AGENCY' O FEDERAL-AGENCY CY� COD5TRICTS' ' <br /> If owner of UST Is a public agency,cor plele the foRmIng:nanse of Supowleor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / IF INDIAN I#OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM A PROCESSOR Q 6OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE i TH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> N6� 0 3 . '� <br /> NIGHTS: NAME(LAST,FIRST) I ( PHONE i WITH AREA DE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box loin irate [—I INDIVIDUAL LOCAL AGENCY 0 STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERAL AGENCY <br /> ( CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to WicaN INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNTYAGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 14T4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blnEkate I SELF INSURED 2 GUARANTEE [-I 3 INSURANCE 0 a SURETY BOND <br /> 5 LETTEROFCREOT O 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 is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD RE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ 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 B SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �k 3 T 7 <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 L3 <br /> LOCATION CODE TONAL CENSUS TRACT# -CVTION�f � SUPVISOR-DISTRICT CODE -OPTIONAL <br /> r <br /> THIS 91ORM AUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLYi <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA MM) FOR003MN7 <br />