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}!L lVM4 C i <br /> ! STATE OF CALIFORNIA ' <br /> + STATE WATER RESOURCES CONTROL BOARDW��' re <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a? <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY C� 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE_ <br /> ONE ITEM F72 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE `j <br /> I. FACILITYfSITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME n 7 NAME OF OPERATOR <br /> PARCEL#(OPTIONAL) <br /> ADORES !. NEAREST CROSS STREET <br /> I <br /> l ! CITY NAME STATE ZIP CODE SITE PHONE 0 1TH AREA CODE <br /> ✓ BOX []CORPORATION [� INDIVIDUAL Cl PARTNERSHIP [] LOCAL-AGENCY �]COUNTY•AGENCY' �STATE-AGENCY' ® FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> 'If owner d UST is a public agency,complete the iollowing:name of Supervisor of division,section,or office which operates the UST <br /> ✓ IF IN111711 DIAN ti OF TANKS AT SITE E.P.A. 1.0,*(optional) <br /> TYPE DF Bt3SINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR D RESERVATION <br /> 0 3 FARM ❑ 4 PROCESSOR 5 OTHER OR7RUST LI <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST,FIRST) <br /> PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> )` I i ►t J r e- (,A0q <br /> NIGHTS: NAME(CAST.FIRS <br /> PHONE a WITH AREA CODE n NIGHTS: NAME(LAST,FIRST) F HONE s WITH AREA COOS <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ]ARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box 10 Indicate 0 INDIVIDUAL © LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION Ca PARTNERSHIP 0 COUNTY-AGENCY � FEDERALAGENCYTATE ZIP CODE PHONE X WITH AREA CODE <br /> CITY NAME <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ o indicate (� INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 3/J Q CORPORATION = PARTNERSHIP © COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE$WITH AREA CODE <br /> CITY NAME <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 /> [—] 1 SELF-INSURED (� 2 GUARANTEE = 3 INSURANCE F7 4 SURETY BOND <br /> ✓ boxbkndcats <br /> O 5 LETTER Or CREDIT li EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be Sent to the tank owner unless box 1 or it is checked. <br /> CHECK ONE BOx INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I,❑ 11.0 111.0 <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 8 SIGNED) <br /> OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# QTY Nt <br /> LOCATION GODE -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR-DISTRICT CODE - NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)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 TAN(K�REGULATKINS FOROW3AV <br /> FORM A{3193) <br />