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t"ou. e <br /> STATE OF CALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Yrl NEW PERMIT 0 3 RENEWAL PERMIT r_–] 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F1 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA ITY NAME NAM. OPERATOR <br /> ADDRESS NEA ST CROSS STREET PARCEL•(OPTIONAL) <br /> �oc <br /> CITY INAML STATEZIP Cz q0 SITE PHONE WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agenc mplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANK AT SITE E.P.A. I.D.4(optional) <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER ORRTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST (�� ONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) PH •WITH AREA CO <br /> go t- � - / & 7-y33o _� o og� ��l�C�� <br /> NIGHTS: NAME(LAST,FIRST) PHONE/#WITH AREA CODE NIGHTS: NAME(LA IRST) PHONE x WITH AREA CODE <br /> r 1 _ <br /> 3,IVY <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M ILING OR STREET DRESS I ✓ box to indicate Le INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> LCORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAME STATE FI <br /> ZIP CODE PHONE X WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicateIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ___TPHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TYFC) HQ 44- - <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDindlcate 1 SELF-INSURED 0 2 GUARANTEE [::] 3 INSURANCE (] 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION [�1199 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 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 (P N 0&SI OWNER'S TITLE DATE MONTH/DAYNFAR <br /> LOCAL AGENCY U E ONLY <br /> COUNTY# JURISDICTION# FACILITY# /7 0 <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMA ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORM A(3/93) FOR0033A-t7 <br />