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t6pUN � <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , os <br />COMPLETE THIS FORM FOR EACH FoIrrY/SITE <br />MARK ONLY F—] t NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TE <br />ONE REM F__1 2 INTERIM PERMIT 71 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />SPA OR FACILITY NPM y <br />ArtA <br />NAME OF OPERATOR <br />ADDRESS PF <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />PHONE # WfT4 AREA ddDE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />CIN NAME <br />STATE <br />ZIPEJ <br />SITE PHONE # WInjA <br />CA <br />1� <br />�!I/ <br />.� <br />BOX <br />TOINDICATE CORPORATION Q INDIVIDUAL P TNERSHIP LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 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 t GAS STATION 2 DISTRIBUTOR <br />F INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM 0 4 PROCESSOR = 5 OTHER <br />RESE <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAPN, FIRST) <br />PHQAIE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WfT4 AREA ddDE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />OWNERS TITLE <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STRE T ADDRE S <br />✓ box b indicate INDIVIDUAL Q LOCAL -AGENCY STATE -AGENCY <br />O I <br />CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />i CITY NAME <br />STATE <br />21P CODE PHONE # WITH AREA CODE <br />1.'.I. TANK OWNER INFORMATIO - (MUST BE COMPLETED) <br />NA O(; OVyNfER CAR F A E FORMATION <br />g 6, -7 bovprQjL� V, VIZ11sk <br />MAS NG OR STREET ADDRESS ef ^ ` / , > ' �1 box bind INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />NAME <br />TY (TK) HQ F4—T4--] - <br />V. PETROLEUM UST FINANCIAL R SPONS <br />✓ <br />box bindicate SELF-INSURED <br />= 5 LETTER OF CREDIT <br />r ��(� COR A = PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />STATE ZIP CODE PHONE # WITH AREA CODE <br />i <br />x A M al (916) 322-9669 if questions arise. <br />BILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED / <br />1� 2 GUARANTEE 31NSURANCE Q 4 SUR BOND <br />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: 1. ❑ if. ❑ 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) <br />OWNERS TITLE <br />DATE MONTWDAYNEAR <br />LOCAL AGENCY USE ONLY <br />�OUNTY # JURISDICTION # FACILITY , <br />y <br />LOCATION CODE - OPTIO CENSUS YACT 8- TIONAL 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 REGULATIONS <br />FORM A (3/93) 101 0 r 1 ;,/- I J FOR0033A-R7 <br />