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0 <br /> �` TYT�TT <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a 4pr <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A , g <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Ej 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD ESS ! NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 9 r - <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box CORPORATION (]INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE <br /> DISTRICTS' <br /> H 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 0 t GAS STATION Q 2 DISTRIBUTOR RE/ IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ON <br /> 3 FARM 4 PROCESSOR 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 /> G G <br /> 40*-1717 15rAlli <br /> NIGHTS- NAME(LAS ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> bum <br /> S <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> LL 13t4V <br /> MAILING OR STREET ADDRESS 9-z.?9 J ✓ box b Indicate INDIVIDUAL = LOCAL-AGENCY TATE-AGENCY <br /> Z� j ��Y�l Z -J—gfrORPORATION PARTNERSHIP F-1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME S ZIP CODE PHONE#WITH AREA CODE <br /> Z3� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Lori u <br /> MAILING OR STREET ADDRESS ✓box b indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> ORPORATION Q PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> 5 S Tv <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box roindicate t SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> =5 LETTER OF CREDIT 6 EXEMPTION (]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.= II.[�] III. <br /> THIS FORM HAS BEEN COMPLETED UNDE ENALT OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY _� �� 7 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE�OPTIONAL CENSUS TRACT •OP77¢N!! SUPVISOR-DISTRICT T10NAL <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 /> FORMA(3/93) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />