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STATE OF CALIFORNIA ' <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 1 NEW PERMIT 0 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION 7 PERMANEN Y CLOSED S E <br /> ONE ITEM 0 2 INTERIM PERMIT F74 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> G <br /> CITY NAME STATE ZIP CODETE PHONE#WITH AREA CODE <br /> r� ��Gr CA �� v <br /> TOINDIICCATE Q CORPORATION ®'INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCYQ FEDERAL-A ENCY' <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 WE 1 GAS STATION 0 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 614 2 0 V Y <br /> NIGHTS: NAME(LAST,FIRST) HON WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD ESS ✓box to indicate ® INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> V'O' /�—�G (�.- Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 7'z1c L C� S SS- <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET RESS ✓ box bindicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> C/ — Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE NE AkVITH AREA CODE <br /> S _/ � `��oZ�J v2d`!' lir-SSU <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ari <br /> TY(TK) <br /> HO <br /> 4 4- - p <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> Q 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.[—] it.[::] III.W <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 8 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AdENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY i <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 INFORMATION ONLY. <br /> FORMA(3193) <br /> OWNER MUST FILE THIS WTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROU D STORAGE TANK REGULATIONS <br /> FOR0633A-R7 <br />