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STATE OFCAUFORWA s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A .w <br /> •C�I��oRM�'. <br /> COMPLETE THIS FORM FOR EACH F CILITYISITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 IN PERM - —❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILRY/SITE INFORMATION&ADDRESS-(MUST BE CO ETED) <br /> `',NAME OF yyERATOR <br /> gRA�ijILITV NAM <br /> d\ r ��`S NEAR TCROSS TR ET �L PARCEL'(OPfIONAy <br /> WADDRESS /1 � r <br /> SITE PHONE 0 WITH AREA CODE <br /> STATE ZIP CODE <br /> CA S3 PARTNERSHIP [] LOCAL-AGENCY COUNTY-AGENCY' STATE•AGENCY' FEDERAL-AGENCY <br /> TOINgCATE O CORPORATION DISTRICTS' <br /> If mne"L U§T is a �..cot*et the fo1lOI Np:nartw of SLOW'Sor of division,sectbn,or office which operates the UST <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.f(optional) <br /> TYP F BUSINESS t GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> ❑ 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE f WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE><WITH AREA CODE <br /> DAYS: A E(LAST,FIRS z v • 6 <br /> _� ` � PHONE f WITH AREA CODE <br /> NIG :NAME T,FIRST) <br /> PHONE WITH AREA E NIGHTS:NAME(LAST,FIRST) <br /> II. PROPERTY OW ER INFORMATION- MUST BE COMPLETED CARE OFF INFORMATION <br /> NAME n 1 jI <br /> ✓boxbkdirate INDIVIDUAL LOCAL-AGENCY STATE•AGfNCY <br /> MAILING OR STREET ADDRESS <br /> sem. C]CORPORATION = PARTNERSHIP (�COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE P NF, WITH AREA CODE <br /> I CI NAME <br /> TA <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) TCRE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ boxbindfcats INDIVIDUAL (]LOCAL-AGENCY 0 STATE-AGENCY <br /> M=ORET ADDRESS <br /> (]CORPORATION PARTNERSHIP F-1 COUNTY-AGENCY D FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- -F El= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Q 1 SELF-INSURED Li 2 GUARANTEE Q 3 INSURANCE i�4 SURETY BOND <br /> Ebindicate (�5 LETTER OF CREDIT 0 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 UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> r <br /> NER'S NAME(PRINTED&SIGNED) <br /> OWNER S TITLE <br /> DATE MONTWDAY/YEAR <br /> = I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � <br /> LOCATION CODE-OPTIONAL CENSUS TRACT f •OPTIONAL <br /> BUPVISOR•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 1AFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIQQQII$,. 3A-R7 <br /> FORMA(3/f3) <br />