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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s` <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA gF{O .1��AME rD NAME OPE TOR <br /> lr /x-GJ/•-1L rr/ <br /> ADD RE S� /j NEAR CF�T. RR SSS STREET PARCEL#(OPrx)NAI) <br /> Wf� f I CAT/On <br /> CITY AME STATE ZIPf.Q�k57 SITE PHONE It WITH AREA CODE <br /> CA <br /> TO v BoxINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY (QA/COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> INDIAN <br /> Y OF TANKS AT SITE E.P.A. I.D.a(optional) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> F <br /> S: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> HTS: NAME(LAST.FIRST) PHONEa WITH AREA CODE NIGHTS: NAME(LAST.FIRST) a WITH AREA COE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box blMicale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENGY Q FEDERAL,AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box binI Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> IQ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [-4F4-1- <br /> V. <br /> 4 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bintlkale Q I SELF-INSURED Q GUARANTEE Q 3INSURANCE Q a SUPETY BONO <br /> Q 5 LETTEROFCREDIT S 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.E-1 II.0 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY q O&YnP JURISDICTION A' FACILITY It <br /> n 40 I �OZ 100101 LI10'42 <br /> LOCATI0 IDE -OPTIONAL CENSUSTRACT�O/ONAL SUPVI$O�DISTRICT CODE -OPTIONAL ry <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS I CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) /,x/1� FOR0033A 5 <br /> a.. .ai <br />