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a <br /> 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 F7 I NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT a AMENDED PERMIT E�] e TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACr NAME / NAMEOFOPERATOR <br /> s�esi 5 /1C✓/Jn <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CiA�I cti CA 53 <br /> I/ BOX <br /> TOINDICATE CORPORATIONNDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY- O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'X owner of UST Is a public agency, Isle The following:name of Supervisor of division,section,IS office whish operates the UST <br /> TYPE OF BUSINESS GAG STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN It;OF TANKS AT SITE E.P.A. I.D.a(op#anag <br /> lir/\ <br /> 0 3 FARM 0 4 PROCESSOR = 6 OTHER OPRESERVATION <br /> 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(LAST.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 /> GUd4 fes�2si Z� <br /> MAILING ORSTREET ADDRESS �T ✓OoxbindkaN Q INDIVIDUAL LOCALAGENCV Q STATE-AGENCY <br /> L' 03 2— CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME ` STATE ZIP CODE PHONE a WITH AREA CODE <br /> G A,-te_C CS � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER 9 Al 2 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0indkata INDIVIDUAL ED LOCAL-AGENCY O STATE AGENCY <br /> =CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkate I� I SELF-INSURED 2 GUARANTEE 3 INSURANCE 1 SURETY BOND <br /> 0 5 LETTEROFCAEDR 0 S EXEMPTION fe 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.[=1 I.= It. <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&S IGNED) OWNER'S TITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION FACILITYr - <br /> 3 y <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL -3e-,)- <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 REGU TIONS <br /> FORMA(393) Fp700.33AA7 <br />