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STATE OF CALIFORNIA w s <br />STATE WATER RESOURCES CONTROL BOARD 3 , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A < .0 <br />/a COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT [-] Il 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br />u <br />ONE ITEM 2 INTERIM PERMIT �� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a 1 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />�, Ar��� <br />NAME OF OPERATO <br />ADDRESS <br />_ <br />PPnf ST <br />NEAREST CROSS STREET PARCEL#(OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CODE <br />CITY NAME <br />STATE <br />Z� ODE � SITE PHONE #WITH AREA CODE <br />I -P✓ <br />CA <br />BOX <br />TO INDICATE <br />C CORPORATION [INDIVIDUAL PARTNERSHIP <br />LOCAL-AGENCYCOUNTY-AGENCY OSTATE-AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION 2 DISTRIBUTOR <br />[—]RESERVNDDIAN <br /># OF TAN GS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR 0 <br />5 OTHER <br />OR TRUST LANDS <br />L <br />AL060C ZCjk,4R <br />EMERGENCY CONTACT PERSON (PRIMARY! CAACDCCNrV rnNTArT OCDQ/Vd crrnAtnADVx _ ....!;-- I <br />DAYS- NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />NIG TS: NAME (LAST. FIRST)� PHONE #WITH AREA COD GHTS: NAME (LAST, FIRST)����� �/ ?^k CODE <br />II- PROPERTY OWNER INFORMATION - (Mt1ST RF ('OMPLFTFD) <br />NAME �V,� <br />�, Ar��� <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESSSS��LI► <br />/0(j G(%, <br />_ <br />PPnf ST <br />✓ box INDIVIDUAL OLOCAL-AGENCY � STATE -AGENCY <br />CORPORATION = PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. LANK UWNtK INI-UMMA I IUN - (MU51 tit <br />NAME OF OWNER <br />MAILIN OR STREET A RESS <br />8 <br />CITY NAME <br />n�J �l4or� <br />CARE OF ADDRESS INFORMATION <br />✓ box to indicate INDIVIDUAL <br />CORPORATION PARTNERSHIP <br />STA ZIP CODE �� <br />C] LOCAL -AGENCY STATE -AGENCY <br />COUNTY -AGENCY FEDERAL -AGENCY <br />HONEWITH AREA CODE <br />/D) 59.2 -- J�j�Gb <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 �3 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHODS) USED <br />✓ tax to indicate I SELF INSURED 2 GUARANTEE [] 3 INSURANCE 4 SURETY BOND <br />L 15 LETTER OF CREDIT 6 EXEMPTION [ J 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LX II. E--] III. E] <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) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUN IY # JURISDICTION # FACILITY # <br />LOCATIONCODE OP710NA1. '?:_ $ TRACT z - OPTIONAL SU R -DISTRICT CODE -OPTIONAL A7� <br />�l U <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, UNLESS THIS IS A CHANGE OF SITE INFOR%ATION ONLY. <br />FORMA (12 e I) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />111 � FOR0033A-R6 <br />