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ti Ve � <br /> STATE OFCAUFORI#A ems' i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , <br /> COMPLETE THIS FORM FOR EACH F rTYISITE °•<„csr'^ <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DEAD FACILITYN E /^ / NAMF^9F-BPERATOR <br /> DEAD <br /> W�„ <br /> ADDRESS NEAREST CflO STREET PARCEL#(OPTIONAL) <br /> CI NAME STATEZIP CODE SITE PHONE#WTH AREA CODE <br /> V Box r cA s'3 3.6 -8'23- 7(LO <br /> TO INDICATE O CORPORATION NDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' E:D STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> If owner of UST is a public DISTRICTS' <br /> p spa oor piete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN 10 OF TANKS AT SITE I E.P.A. I.D.#(cplarwl) <br /> RESERVATION J9 <br /> ❑ 3 FARM ❑ 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY�AME(LAST ST) qq PHONE N WITH AREA/TCODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ] <br /> NIGHTS: N E(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREAOODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILI�G/O�R STREE ADDRESS ✓ box bintlkaM 0 INDIVIDUAL O LOCAL-AGENCY I�STATE-AGENCY <br /> (�J 0 CORPORATION I1 PARTNERSHIP I�COUNTYAGENCY Q FEDERAL-AGENCY <br /> C NAME Ir"I STATE� ZIP CODE PHONE#WITH AREA CODE <br /> A. ( <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G.D <br /> MAILING OR STREET ADDRESS ✓ boabihdksu [:1 INDIVIDUAL O LOCAL-AGENCY I1 STATE-AGENCY <br /> f�CORPORATION Q PARTNERSHIP ED COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREACODE. <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -\ = I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkate E-1 I SELF INSURED 2 GUARANTEE = 3 INSURANCE L-J 4 SURETVBOND <br /> f� 5 LETTEROFCBEDIT D 6 EXEMPTION L-1 gp OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) j OWNER'STITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> T . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS Lis A CHANGE OF SITE INFORMATION ONL” <br /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> , <br />