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tboun [g <br /> t <br /> STATE OF CALIFORNIA <br /> IA ;o <br /> STATE WATER RESOURCES CONTROL BOARD S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ,., 0 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �'k fom0`' <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> CRA OR FACILITY N/1jrE I NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> `/a/ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Gaa r- cA --1Zzlp <br /> BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS F--] 1 GAS STATION E�] 2 DISTRIBUTOR 0 ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optionaq <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> /^t C <br /> MAILING OR STREET ADDRESS ✓box b indicate ED INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE IP CODE y <br /> el�gj <br /> E#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> U <br /> MAILING OR STREET ADDRESS/ ✓box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Cf/ �j#f j�/J rj i CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITYN M STATE ZIP CODE PHONE#WITH AREA CODE <br /> r-v 9 5Z 3 Z Zoe f S�2 0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box lo indicate E=1 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE E=1 4 SURETY BOND <br /> =5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 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.D II.0 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 8 SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ('03 <br /> AF- <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 iwodf&m bALY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) • . FOR0033A-R7 <br />