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\a[ �s r <br /> STATEOFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 1Rr5 CHANGE OF INFORMATION O 7 PERMANENTLY CL SSE SITE <br /> ONE REM O 2 INTERIM PERMIT A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE Srp <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) JC/ <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> n Mcd/k-C <br /> ADD7zL/ LQnc NEAREST CROSS STREET ) PMCELa(OPrpNAU <br /> L G L/V /GU1�4 / <br /> CITYNA <br /> �C STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> CA 1T7s70 S <br /> TO DIox <br /> ATE O CORPORATION 0 INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY <br /> •If Amer d UST Is a public agency,complete the following:narre of Su pervisor of dDISTRICTS <br /> - Q COUNTY-AGENCY' STATE AGENCY' FEDERAL-AGENCY'hiabn,sed'bn, r office <br /> which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.i(optimal) <br /> RESERVATION �a�Y <br /> 3 FARM 4 PgOCESSOR 0 5 OTHER OR TRUST LANDS v <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIgST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER NFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boablydkaN INDIVIDUAL = LOCAL AGENCY E-:J STATE AGENCY <br /> D CORPORATION O PARTNERSHIP l= COUNTY,IGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MU BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ hor bindbale INDIVIDUAL <br /> O LOCAL-AGENCY O STATEAGENCY <br /> _ O CORPORATION O PARTNERSHIP =COUNTY AGENCY Q FEDEML-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOU%COM <br /> -Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTTED)-IDENTIFY THE METHOD(S) USED <br /> ✓Iwa bintlbate 1 SELF INSURED 0 2 GUARANTEE O 3 INSURANCE O a SURETY BOND <br /> O 5 LETTEROFCREOIT O 6 EXEMPTION = 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O 11.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® z31 I 1- 3- 5` <br /> LOCATION CODE -OPTIONAL / CENSUS TRACT# .OPTIONAL SUPVISOR-DISTRICT CODE -uriiOrmIt. <br /> ,zz- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA /� <br /> / FOR0063Mfl7 <br />