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STATE OF CALIFORNIA =� <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD ;n,qg' :8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A :- , ,s <br /> COMPLETE THIS FORM FOR EACH FACIUTYISITE `'��^�a"��. <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERA OR �Qrl /��� <br /> D( M �� <br /> ADDRESS NEARESTCRP STREEPARCELN(OPTIONAL) <br /> CITY NAME, / STATE ZIP C ��I SITE PHONE#WITH AREA CODE <br /> Ck --a'1 CA <br /> T INDICATE0BoxfdOORWRATION I�INDIVN)UAL E:] PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL AGENCY' <br /> DISTRICTS' <br /> ff wmer Of UST Is a public agency,cornplete the folImIng:name of Supervisor of oNkbn,section,or office which Operates the UST <br /> TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR RESEIF RVATDION #OF TANKS AT SITE E.P.A. I.D.#(Opauwg <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: AME LAST,FIRST) PHONE 0 WITH AREA CDAY$: NAME(LAST,FIRST) PH #WITH AREAaO/I <br /> 7p <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODENIGHT . NAME(LAST,FIRST) PHONE S WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / // // CARE OF ADDRESS INFORMATION <br /> MAILING O ADDRESS ^ p� (�S ✓ bmbindlwl° =1 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> •Y//T— ✓• CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME . G / STIP ZIP CODE Q PHO ITH AREA CODE / <br /> III. TANK OWNER INFORMATION•(MUST E COMPLETED) `//tel 9 V 92 7 <br /> NAMEOF ER // CA RE OF ADDRESS INFORMATION <br /> /l�Lo y1�J�'O/.CG(�Y/ <br /> MAILING OR STREET ADDRESS T�S 5 ✓ Doc blMk#e O INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> PiT-EORPORATN)N PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME 17 ZIP CODEPHONE#WITH AREA CODE <br /> a-o : 7I <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. 5477-34W3 <br /> TY(TK) HQ M44- - 0`2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindcale O I SELF INSURED O 2 GUARANTEE O 3 INSURANCE 7_1 71ETYPOND <br /> 5 LETTEROFCREDT D S EXEMPTION D 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= it.O III. <br /> TH)S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TlfUE AND CORRECT <br /> OWNER' NA / <br /> ME(PRINTEDSIGNED) OWNER'S TITLE DATE MON➢LDAY/YEAR <br /> MQ//61 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UMLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> n'�Y I/A, ,� FORaWs1A7 <br /> FORM A(393) 'a—\\/, <br />