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�A.uRcca <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY a 1 NEW PERMIT Q--3--RENEWAL PERMIT O 5 CHANGE OF INFORMATION F-� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA�FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS TREE? PAK ELI(OPTIONAL) <br /> CITY NAME STATE ZIP�SE��� S TE PHONE#WITH AREA CODE <br /> ✓BOX CORPORATION [:D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYC�] STATE-AGENCY' a FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owner of UST is a public agency.m lets the fdllowing:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR Q ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LA T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Pfd <br /> ' N/v`4 .�' 0 ��' .? <br /> NI TS: <br /> ME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH ARE t CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> C�j�o CSU/—' ✓i' r UA) � li E�12,t7 G <br /> MAILING STREET ADDRESS t ` ✓ box to indcate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> r " v�—/ ORPORATION PARTNERSHIP <br /> CJ, 13�,�/ ,S� []COUNTY-AGENCY Cj FEDERAL-AGENCY <br /> CITY NAME ST TE ZIP CODE P NE# ITH AREA CODE SrJ <br /> 95U 7J--P oyS Gc <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM�E�ER CARE OF ADDRESS INFORMATION <br /> il/Vf11-c'k- iledfRL- <br /> MAILING O STREET ADDRESS ✓ box to icate INDIVIDUAL CJ LOCAL-AGENCY (�STATE-AGENCY <br /> �G- �' ' �� C)� ORPORATION PARTNERSHIP COUNTY-AGENCY Q FEOERAL•AGENCY <br /> CITY NAME STA/ITE ZIP CODE POQNE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQM44- - �` 7 j � <br /> V. PETROLEUM U T FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicateEff 1 SELF-INSURED I3 2 GUARANTEE f1 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT CI 6 EXEMPTION 0 7 STATE FUND <br /> (�8 STATE FUND b CHIEF FINANCIAL OFFICER LETTER [�:] 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 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 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.lJ II.El III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OV S NAME(P NTED&SIGNATURE) ! TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> 1 � <br /> J A <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT!f -OPT;ONA-' 1 SUPVISOR-DISTRICT CODE -OPTICN I L <br /> THIS FORM MUST B6 ACCOMPANIED BY AT LEAS 1(1)OR MORE PEFiWT APPLICATION- FOR,A 6,UNLESS THIS IS A CHANGE OF SITE INFORNIATION ONLY. <br /> OWNER N!'JST FILE THIS FOR H T d=LOCA A.G_t.; (1"?PL EtAENT1.,NG THEUNOERG,R�STO A_?E TANS(REGUL.;TiO,I <br />