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t�pup <br /> STATE OF CALIFORNIA Arc tiA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A �� , s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �\ NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> NQS <br /> ADDRESS t NEAREST CR SS STREET PARCEL#(OPrIONAW CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 11 209- 4W 2- q 530 <br /> ✓ BOX ORPORATION INDIVIDUAL �PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' E=) FEDERAL-AGENCY' <br /> TO INDICATE <br /> ;<_C 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 0 2 DISTRIBUTOR 0 RESE F INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM = 4 PROCESSOR 5e5 OTHER OR TRUST LANDS l <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST PHONE#WITH AREA— <br /> DAYS: (LAST,FIRST �PHO`NE WITH AREA CODE <br /> _Ly <br /> NIGHTS: NA E(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAM (LAST FIRS PHO E#WI H AREA CODE <br /> n) 16 -3 /ga 3-14/ C? -3 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME S 1-= S 1=r-)1 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box ID Indicate EZIDIVIDUAL (] LOCAL-AGENCY (] STATE-AGENCY <br /> ,O ` =CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAI � ' 5 ST TE ZIP�DE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) S f �O( <br /> NAME OF OWNER ` CARE OF ADDRESS INFORMATION <br /> MAILING TREET ADDRESS / ✓ box b indicate INDIVIDUAL (� LOCAL-AGENCY (� STATE-AGENCY <br /> 1 O ( ��� =CORPORATION = PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMEW- ` ST E ZIP CO E PHONE#WITH AREA CODE <br /> ' 7 - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -1014b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 1 SELF.INSURED F__1 2 GUARANTEE E�] 3 INSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT =6 EXEMPTION E0-9 OTHER ST%k. aC(/+J D <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: <br /> THIS FOR HAS BE COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME ANTED IGNED) s'r �jE^J�y-p OWNE TITLE DATE MONTH/DAY/YEAR <br /> AG USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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 IWORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � � FOR0003A-R7 <br /> f <br /> r' <br />