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0 eWy <br /> STATEOFCALIFORWA <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 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION 8&ADDRESS•(MUST BE COMPLETED) / <br /> DBAOR FACILITY E NAME OF OPERATOR <br /> /Y <br /> ADDRESS NEAREST CROSS STREET PARCEL kI0PTI0NAU <br /> 07 f / iC <br /> CITY NAME <br /> STATE ZIP CODE TE PH E#WITH AREA CODE <br /> ✓ BOX CA <br /> TO INDICATE O CORPORATION a INDIVIDUAL PARTNERSHIP O LOCAUAGENCY 0 COUNTY#GENCV• O STATEdGENCY' O FEDERAL#GENCY' <br /> If owner o(UST Is a public agency,mnplate the following:name of Supervisor of division,section.or offic, which <br /> operates the UST <br /> TYPE OF BUSINE 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.R(optional) <br /> ARM O 6 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> v 00 <br /> NIGHTS: NAME(LAST,FIRST) AI WITH AREA E NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> PHONE# <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM <br /> CARE OF ADDRESS INFORMATION <br /> MAILING STREET ADDRES�Sf ✓ pox blMicate INDIVIDUAL I� LOCAL-AGENCY <br /> �' / CORPORATION I� PARTNERSHIP I= COUNTY-AGENCY STATEAGENCV <br /> CITY NAME CO FEDERALAGENCV <br /> STATE' ZIP CODE PHONE s WITH AREA CODE <br /> F 7vla` <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMED OWNER CARE OF ADDRESS INFORMATION <br /> MAILING�RSTREEti D-DRESV./t�om``r G'2'+ I�✓ box bimic— Q INDIVIDUAL ED LOCAL-AGENCY <br /> 0 STATE AGENCY <br /> CORPORATION <br /> [=] PARTNERSHIP <br /> CITU NAME COUNTY-AGENCY 0 FEDERAL AGEII <br /> STATE ZIP CODE <br /> �` PHONE>I WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box lo indicate I SELF-INSURED 2 GUARANTEE =3 INSURANCE <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION O %OTHER <SURETYBOND <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 ILO III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME IF RINTED S SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ED 1f 7�TJL <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# - 9 <br /> OPTIONAL 9UPVISOR DISTMIG T GUIDE -OPTIONAL <br /> IZ cl y3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMS,UNLESS THIS IS A CHANGE OF SITE DF MATION ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM <br /> . FORWB3Mi7 <br /> I <br />