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• 0 <br /> STATEOFCAUFOFHA ° 'o <br /> �. STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A Yw ; <br /> ril COMPLETE THIS FORM FOR EA FACILfTY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER V DSI <br /> ONE REM O 2 INTERIM PERMIT d AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC NAM - NAME OF <br /> ADDRESSW• ' NEAREST CROSS STREET Iv 'G PARCEL#(OPIONAU <br /> sq- <br /> CITY NAME 5 ' C1� — `G!V/ 1Y/ STATECA ZIP ^� SITE PH NE t LTH AREA CA��� <br /> //! ✓ L/j iC/!1 <br /> ✓ BOX CORPORATION INDIVIDUAL PARTNERSHIP LOCAL AGENCY Q COUNTYAGENCY' O STATEAGENCY' O FEDERAL-AGENCY' <br /> TO INDCATE DISTRICTS' <br /> It owner (UST is a public agency,caMlele the following:name of SUPemsor of dwsion,section,or off ice which aperale,the UST <br /> TYPE OF BUSINESS t GAS STATION o 2 DISTRIBUTORO RESERVATION✓ IF INDIAN A OF TAN SA7 SITE 'c.P.A 1.D.s(opTwia) <br /> J <br /> 3 FARM Q d PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA COOS <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSJ be,bind"Is [:1INDIVIDUAL LOCAL-AGENCY IJ STATE-AGENCY <br /> 6 L O CORPORATION = PARTNERSHIP C COUNTY AGENCY FEDERALAGENCY <br /> CITY NAMESTATE I ZIP CODE PHONE a WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS T' ✓ tabmt= = INDIVIDUAL C' LOCAL AGENCY STATE AGENCY <br /> IV =CORPORATION 1= PARTNERSHIP G CCUHTY AGENCY Q FEDEPAL AGENCY <br /> CITY NAME L, STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4A]_ -0-Yi m <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOO(S) USED <br /> ✓ bos birbicate 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> D 5 LETTEROFCREDT Q B EXEMPTION Q 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= IL= III.CI <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'STITLE DATE MCNTWDAYNEAR <br /> LOCAL AGENCY USE ONLY t4vq I <br /> COUNTY# JURISDICTION# FACILITY# 10� <br /> f�_q L <br /> LOCATION COOfs- TIONAL (CENSUS TRACT -(WT70 O SUPVISOR-DISTRICTCOE - <br /> /V1 3 � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION• FORM B,UNLESS TAIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A1393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 3A4R7 <br /> • • � � r <br />