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_ COMPLETE THIS FORM FORE FACILITYISITE <br />MARK ONLY F -1T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED S <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br />1 ennu ITVIOITC UMCnORMATInAl A AnnRFA2C. fRAIICT RF POAAPI FTFO1 <br />DBA ACI ITV NAME JJ <br />�1�->r/�S�i9f <br />NAME OF OPERATOR <br />STATE OF CALIFORNIA <br />NIGHTS: NAME (LAST, FIRST) <br />STATE WATER RESOURCES CONTROL BOARD <br />w o <br />/ APPLICATION - FORM A <br />UNDERGROUND STORAGE TANK PERMIT <br />�;! ; �, „ o� <br />_ COMPLETE THIS FORM FORE FACILITYISITE <br />MARK ONLY F -1T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED S <br />ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br />1 ennu ITVIOITC UMCnORMATInAl A AnnRFA2C. fRAIICT RF POAAPI FTFO1 <br />DBA ACI ITV NAME JJ <br />�1�->r/�S�i9f <br />NAME OF OPERATOR <br />i i <br />NIGHTS: NAME (LAST, FIRST) <br />AD R BS <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />r n''e-� <br />CITVN E <br />STATE <br />ZIP E <br />SITE PHONE #WITH AREA CODE <br />CA <br />BOX <br />TOIND.CATE CORPORATION E-1 INDIVIDUAL PARTNERSHIP 0 �BI-AG NCY (] COUNTY -AGENCY E=1 STATE -AGENCY FEDERALAGENCY <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR/ <br />IFINDIAN <br />I#OF TANKIAT SITE <br />E. P. A. I. D. # (cpfmnal) <br />O <br />ON <br />0 3 FARM 0 4 PROC SSOR Q 5OTHER <br />OR TRUST LANDS <br />/ <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE #WITH AREA CODE <br />DAYS: NAME (LAST. FIRST) <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) # WtTH AREA CODE <br />It. I'MUPtH I T UW Nt H I N r -U HMA I IUIN• kIVIUJI DC UUIVIr LC I CV <br />NAME I CARE OF ADDRESS INFORMATION <br />ADDRESS I ✓ box bindicme INDIVIDUAL O LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION 0 PARTNERSHIP E -1 COUNTYAGENCY (] FEDERAL -AGENCY <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />CIN NAME <br />✓ bolt INkme (] INDIVIDUAL D LOCAL -AGENCY O STATE -AGENCY <br />= CORPORATION 0 PARTNERSHIP COUNTY -AGENCY 0 FEDERALAGENCY <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER • Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 44 - b Z WI <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COM LETED) - IDENTIFY THE METHOD(S) USED <br />✓ box biMbab I SELF-INSURED 0 OtUARANTEE 0 3 INSURANCE =1 4 SURETY BOND <br />5 LETTER OF CREDIT EV6 EXEMPTION E__] 99 OTHER <br />��jj l <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles oxTo�l' chLe&ed: � ) <br />CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 0 III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME(PRINTED& SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY# JURISDICTION# FACILITY# <br />® N4T)020 1 1 Ill <br />LOCATION CODE - T NAL CENSUS T TAy OP AL SUPVISOR- DISTRICT CODE -OPTIONAL <br />'-)10�' Z <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (7) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />rV.. Ap.-a ) <br />tU W53AC <br />