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0 <br /> roUR C <br /> STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 1 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 ( 12-9 <br /> CITY NAME TAYE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Shoe k6-, Ca I q 57-1 L) - 3 11 1 <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY E�:]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 0 ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION 1 l� <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1-11 I -3111 36 - <br /> NIGHTS: NAME(LAAT,FIRS PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> (2 TI jZjaija, q► - i 5 1 Z 2 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION —1 <br /> MAILING OR STREET ADDRESS ✓ box toindicate =INDIVIDdAL = LOCAL-AGENCY (] STATE-AGENCY <br /> n WCORPORATION 0 PARTNERSHIP =COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> m 4 bZ►IDIQ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> r * -,A CORPORATION = PARTNERSHIP E::] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 14 ,A I CIA q,3 0 1 C2hCN 5&5- 2� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HOF4 4- - Z a.l O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate :J�SELF-INSURED ED 2 GUARANTEE E:)3 INSURANCE E::]4 SURETY BOND <br /> =5 LETTEROFCREDIT =6 EXEMPTION 0 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.❑ llL� <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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> ��r rUn r UJX s ci <br /> LOCAL AGENCY 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&T(1)OR MORE PERW APPLICATION• FORM B,UNILE&IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR111111111111TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIMMORAGE TANK REGULATIONS <br /> FORM A(3/93) FOR0033A-R7 <br />