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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W nr n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Xt NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION O ED <br /> 7 PERMANENTLY CLOS <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> S (__ czer I -7- STAT)OA S:_1t 6 e r1= IN o1?, b .p, '�c�� <br /> ADDRESSII NEAREST CROSS STREET s PARCEL#(OPTIONAL) <br /> CIT,,Y,N,AME STATE ZIP ODE iF SITE PHONE#WITH AREA CODE <br /> TOINDICATECORPORATION (l INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY l�STATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <br /> it 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 t GAS STATION Q 2 DISTRIBUTOR <br /> TE��FIESERVATION✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHETRUST 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 /> GHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SWUle, 61(_ a)mP1q1VV <br /> MAILING OR STREET ADDRESS ✓ box b Indicate = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> WILL" Fks , (CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN AME STATE <br /> 21P CODE ) PHONE#WITH AREA CODE _ <br /> �Q�-Ig) 61 1Q S <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS r ✓ box b indicate <br /> � (] INDIVIDUAL OLOCAL-AGENCY � STATE-AGENCY <br /> F , o® CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE HONE WITH AREA CODE <br /> CL <br /> 1 �!� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> -I U 110 111 <br /> NYNQ3G <br /> V. PETROLEUM-IST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicateSELF-INSURED El 2 GUARANTEE 0'3 INSURANCE E�D 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION 0 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.a II.[m 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 M TH/DAY/YFJ► <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION#m r FACILITY#� I i$•� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-OLSTRICT CODE -OPnONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 6 A CHANGE OF StIE INFORMATION ONLY. <br /> FORMA(3193) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUWSTORAGE TANK REGULATIM <br /> FOR0033A•R7 <br />