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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT X5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED�� <br /> ONE TEEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F CILITY NAME C L NAME OF OPERAT R <br /> Ff, <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 101 . ! 7 ul1 r Ke t <br /> CITY NAME / J STATE ZIP CODE SI HONE r WITH AREA CODE <br /> I/ BOX <br /> TOINDICATE L-1 CORPORATION I7] INDIVIDUALPARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY. 17-:1 STATE-AGENCY' = FEDERAL-AGENCY' <br /> X/\ DGTRICTS' <br /> It owner of UST Is a public agency,complete the following:name of Superv''sor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 R V IF INDIAN <br /> a OF TAS AT SITE E.P.A. I.D.a(aptionaf) <br /> Q 3 FARM 4 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 ILAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box ID indicate [] INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATS ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> (_]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-f4--]- C)J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate I SELF-INSURED 2 GUARANTEE (] 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT ®6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND 13ILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> FCHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.L—] III. <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY 'A <br /> COUNTY# .JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE -OIP77ONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAMONS <br /> FORM A(3(93) FOROMWIP17 <br />