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As Ou <br /> C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W„ � v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ,, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS T <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 4__� <br /> r7Ra OR FACILITY NAME NAME OF OPERATQ``R <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL N(OPTIONAL► <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY [] COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 11 owner d UST is a public agency,complete the following;name o1 Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS [--j t GAS STATION F_� 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.R(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION I <br /> 0 0 OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA S: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAY s.,NAME(LAST,FI T] PHONE#WITH AREA CODE <br /> NIGHTS: NAME{LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE K WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> i F_ <br /> MAILING OR STREET ESS ✓ box b indicate 0 INDIVIDUAL [ LOCALAGENCY =STATE-AGENCY <br /> '_'� [ D CORPORATION PARTNERSHIP ® COUNTY-AGENCY 0 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 /> i <br /> MAILING OR STREET ADDRESS ✓ box bindcate INDIVIDUAL 0 LOCAL-AGENCY [_]STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP [__1 COUNTY-AGENCY L-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x 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- -Ir-4 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box It)Indicate 0 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE EI'4 SURETY WND <br /> D 5 LETTER OF CREDIT 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: I.El H,[] III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,I5 TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE [SATE MONTWDAYNW <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m t7 \ <br /> " V <br /> LOCATION CODE -OPTIONAL CENSUS TRACT II •OPTIONAL SUPVISOR-DISTRICT CODE -OPROAIAL kil-7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA{3re3) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN STORAGE TANK REGULATIONS <br /> � FO(tOD37A�i7 <br />