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*AA. <br /> STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FA Y/SITE �.,,,e„�.•' <br /> MARK ONLY L__1 i NEW PERMIT O 3 RENEWAL PERMIT6 CHANGE OF INFORMATION O 7 PERM OSED SITE <br /> ONE REM _) 2 INTERIM PERMIT O 4 AMENDED PERMIT Ej 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION b ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME ) NAME OF OPERATOR <br /> �C <br /> ADDRESS 45/i-I ,7 ,� NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> CITY NAME 'j�'IL1 <br /> /,J STACEA ZIpe1G9 <br /> OE /' '] / 917E L N A ITH AREA CODE <br /> V BOXTO INDICATE r7-)CORPORATION INDIVIDUAL Ij PARTNEASIAP Ij LOCAL AGENCY COUNTYAGENCYED STATE-AGENCY' O FFDEIIALAGENCY' <br /> DISTRICTS' <br /> 'N owner d UST s a public agency.complae the Ioliming:named SepeNlsor of division,ssdbn,w oUice which opersks,the UST <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTORQ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.A(gotAVMg <br /> RES✓ERVATION <br /> [] 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: N ( ST,F RST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST. IRST) PHONE A WITH AREA CODE NIGHTS: NA T,FIRST) PHONE A WITH AREACODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ) ✓ aIs INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> t G1 { V COTIPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP COD ./ PHONE A WITH AREA CODE <br /> S y, <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNEIR CARE OF ADDRESS INFORMATION <br /> 7`Ly <br /> MAILING OR STREET ADDRESS G�-� ✓ boT birdkats (] INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CSE 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) HO j414+[__] _] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bos biMkaM 1 SELF INSURED 0 2 GUARANTEE [_1 SJINiURANCE 0 A SURETYBOND <br /> C] 5 LETTEROFCREDT Q 6 EXEMPTION =99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.0 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE ITS NAME(PRINTED 6 SIGNE D) OWNER'STITLE DATE MONTWDAY/YFAR <br /> Z 1' L'L <br /> LOCAL AGENCY USE ONLY �L/l <br /> COODU-NN�TTYY�a JURISDICTION a FACILITY• <br /> L[1�J <br /> /i LOCATIONCODEiogr AL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL - <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> OWNER MUST FILE THIS FORI,H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br /> FORM A(393) aW FORCA991417 <br />