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Y STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION O 7 PERMANENTLY GLOBE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT E a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA Oq FACILITY NA NAME OF OPERATOR <br /> ADDRESS NEARESTCROSS SW <br /> Q PARCEL (OPTIONAL) <br /> r � <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE a WITH AREA CODE <br /> OG CA 9 b <br /> I/ BOX <br /> TO INDICATE D CORPORATIONINDIVIWAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERALAGEWY- <br /> �� , DISTRICTS' <br /> 'If owner of UST Is a public agency,complete the following:name of Supervbor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF T�SITE E.P.A. 1.D.a(ttoo nal) <br /> 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION <br /> O O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA : NAME(L ST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Lu CA�U �' =v!ETH - .3JNIGHTS: NA�(LAST,FI /I DE/ NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> e n e Lz <br /> MAILING OR ST fl AD REBS ✓Dox biMkaN OINOIYIDUAL O LOCAbAGENCY <br /> y�} 0 STATE-AGENCY <br /> 'j <br /> P O. ED CORPORATION 0 PARTNERSHIP Q COUNrY.AGENCY Q FEDEIULAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> a <br /> MAILING ORS R ET ADDRESS ✓box biMbah, INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE At 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-F4--]- <br /> (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> =12 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> 6 E%EMPTION Q 99 OTHER <br /> Ot�V Legal notification and billing will be sent 10 the tank owner unless box I or II is checked. <br /> D FOR LEGAL NOTIFICATIONS AND BILLING: <br /> OF PERJURY,AND TO THE BEST OF AdY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S TITLE DATE MONTWDAYNEAR <br /> JURISDICTION 8 p <br /> SUPVISOR-DISTRICT <br /> WE RMITAPPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SPIE INFORMATION ONLY.ENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A�,(39��3�') <br /> FGR0067AA7 <br /> 4 <br />