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STATE OF CALIFORNIA ��'cfia '^x`os <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A �� tl° <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE In o <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY EL <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA..QR1FACILIN NAM ^n -rr„ e,� NA OF OPERA7pR -e <br /> ADDRESS rjJL V NEAREST CROSSSTREETPARCEL Y(OPTIONAL) <br /> CITY NAMES fO STATE A ZIP CODE 5A6 <br /> SITE PHONE#WITH AREA CODE <br /> ✓Box CORPORATION INDIVIDUAL D PARTNERSHIP 0 LOCAL-AGENCY STATE-AG INDICATE DISTRICTS ENCY' OFEDERAL-AGENCY' <br /> X owneroIUSTk a public agenry,complete the following:name d supervisorol&nulon,section or office whiob operates the UST <br /> TYPE OF BUSINESS ?] 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN J#OFTANKS AT SITE E.P.A. I.D.#(optionall <br /> 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR RESERVATION <br /> TRUST(ANDS <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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bexlo ildc"a O INDMDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> =CORPORATION Q PARTNERSHIP =COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxlotdicale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP a COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 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 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-WSURED O 2 GUARANTEE l=3 INSURANCE 0 4 SURETY BOND Q 5 LETTEROFCREDIT = 6 EXEMPTION =7 STATE FUND <br /> B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =B STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM f= 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: I.❑ 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY R a 313 o y- <br /> COUNTY# JURISDICTION# FACILITY# <br /> m ETTI 101613161 <br /> LOCATION CODE rOPT/ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRaFeIf!(jNAL <br /> d I OV <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 /> FORM A(fi-BS) <br /> OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br /> 1 /�— ^yX-M <br />