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w �;, y, :�,� v*sw,, r #'��•'aara�'e��, �t%-�� �? �w't:��,t-:wee - R; <br /> l m151 <br /> STATE OF CAUFORNIA rey�o <br /> STATE WATER RESOURCES CONTROL BOARD W y 1 v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� ffios <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE lifoRN'- <br /> MARK ONLY 0 t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE_ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITTY NAME NAME OF OPERATOR <br /> ADDRE NEAREST CROSS ST ET I PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> k CA ? D <br /> TINDICATE (�CORPORATION 0 INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-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 a ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.0(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIST) PHONE X W�AREA'CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> IGHTS:NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMeE, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORE SSr �A ✓ box to indicate HkINDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> 1A© CORPORATION =1PIARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE PHONE i WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> �L CARE OF ADDRESS INFORMATION <br /> •'x/44', /ill Er'•► <br /> MAILING OR STREET ADDRESS ✓box to indicate 73DIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> —74b Q CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY E�j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Io Indicate [�] 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 0 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 /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TTTLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m 7; -:5 A� <br /> LOCATION CODE -OPTIONAL SUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> A 649 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)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 /> FORMA(3193) � FOR0003A-117 <br />