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• � . e6cu- �s <br /> STATE OF CAUFOItr)IA <br /> STATE WATER RESOURCES CONTROL BOARD W��r >b a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE � 12"PI <br /> e- <br /> MARK ONLY 0 3 RENEWAL PERMIT Aln 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT n 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME`�✓, r77 NAME OF OPERATOR /,' <br /> ADDRESS C V/Ir` NEAREST CROSS STREET /l/ PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> f �1 CA <br /> TOINDIICO TE 0 CORPORATION (]INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCYFEDERAL-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 1 GAS STATION Q 2 DISTRIBUTOR0 RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM F-1 4 PROCESSOR Q 5 OTHER OR TRUST LANDS �J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE# TH E CO DAYS' NAME(LAST,FIRS WITH ARODE <br /> NIGHTS: NAME(LAST,FIRST) PH NE#WI H ARJE16WDE NIGHTS: AME(LAST,FIRST) OA ITH AREA�QDE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD RE t ✓ box b indicate F__1 INDIVIDUAL LOCAL-AGENCY =STATE-AGENCY <br /> C =CORPORATION PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NA E C-04 STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER f-, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <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 /> ✓ <br /> box bindicate =2 GUARANTEE D 3 INSURANCE _ Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION 99 OTHER 57�i1'� ciL;T z1 <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: 1.0 if.[--1 III.0 <br /> THIS FORM HAS BEEN CO PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME INTED NEI) OWNER'S TRL� DATE M�OfNT AY R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 1 013 1D <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 INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORM A(3193) FOR0033A-R7 <br />