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t60UN � <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD ; .u�� .'o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A, os <br />r - <br />r COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY tK1 t NEW PERMIT F—] 3 RENEWAL PERMIT, O 5 CHANGE OF INFORMATION [:�] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM F__1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERA R / <br />^_ <br />ADDRESS <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NEAREST CAM STREET <br />PARCEL # (O"IONAW <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />�Q 7 <br />CORPORATION O PARTNERSMP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAE <br />STA <br />STATE <br />CA <br />ZIP <br />TE PIJONE WITH AREA CODE <br />Box <br />TO INDICATE t9k=1DRATION Q INDIVIDUAL Q PARTNERSHIP <br />Q LOCAL -AGENCY Q COUNTY -AGENCY' <br />Q STATE -AGENCY' Q FEDERAL -AGENCY' <br />DISTRICTS' <br />' H 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 Q 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I, D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON fSECONDARYI - eotinnal <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE x WITH AREA CODE <br />t! th ► �Tl-' — ii <br />(1 v ~7"' GO <br />NIGHT#*. NAME (LAS FIRST) Rv. # WITHAREA-CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />f ciZr_e6 <br />✓ b" b Indkf Q INDIYDMAL <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CAREOF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />(1 v ~7"' GO <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />MAILING S rREET ADDRESS <br />✓ b" b Indkf Q INDIYDMAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />�Q 7 <br />CORPORATION O PARTNERSMP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY <br />STA <br />ZIP <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETEDI <br />NAME OF OWNER I <br />�w�* <br />.�—,K' As <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box b indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ <br />[4t4- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - PUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box toindicate Q 1 SELF-INSURED a 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br />5 LETTER OF CREDIT Q 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: I. El II. F-1 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 ✓3, SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />I <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR- DISTRICT CODE - OPTIONAL <br />g , <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (11 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) FOR0033A-i7 <br />