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0 • E60UP L <br /> f ow.rr c <br /> STATE OF CALIFORNIA <br /> r 0 <br /> STATE WATER RESOURCES CONTROL BOARD F m g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA FAC1LITY1SITE -L <br /> MARK ONLY F-1I NEW PERMIT F73 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA clelly NAM NAME OF OP RATO <br /> ADDRESS ,! NEAREST CROSS STREET !f PARCEL#(OFrIONAL) <br /> CITY NAME STATE ZIP CO SITE PHONE ITH AREA CODE <br /> CA <br /> 5merM2 <br /> T INDICATE0 Box �CORPORATION [___1 INDIVIDUAL I] PARTNERSHIP [� LOCAL-AGENCY =1 COUNTY-AGENCY' [] STATE-AGENCY' O FEOERAL-AGENCY' <br /> DISTRICTS' <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 ❑ t GAS STATION ❑ 2 DISTRIBUTOR Q RESERVATION <br /> AN TYPEOF TAN SST SITE E.P.A. I.D.f1(optronaf) <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME.jLAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL D LOCAL-AGENCY [j STATE-AGENCY <br /> ®CORPORATION D PARTNERSHIP l] COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF®RST—REET <br /> NER CARE OF ADDRESS INFORMATION <br /> MAILING ADDRESS .� box toindicale 0 INDIVIDUAL 0 LOCAL-AGENCY a STATE-AGENCY <br /> A. A141 All CORPORATkON PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME LV 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 4 4- -E_L <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> V box to indicate I SELF-INSURED t]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT =6 EXEMPTION M 99 OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless box l or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND WILLING: I.❑ if.❑ NL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO T14E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PFhNTEO&SIGNED) OWNER'S TITLE DATE MONTHlDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# � FACIL rrY# — <br /> 5P,P- I� 1112-10 1 �� b 1) <br /> LOCATION COIF- TIONAL JCENSUS TRACT# -OPTION 0 SUPVISOR-DISTRICT CODE 77ONAL / <br /> 23. !r <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION FORM B,UNLESS T IS IS A CHANGE OF SITE INFORMATION ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3183) 1 ,, ' �/ P�=��7 <br /> 0 P ,)G- <br />