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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A „ <br /> _ Cl4nolNJ <br /> COMPLETETHIS FORM FOR EA RYISITE <br /> MARK ONLYr❑--II t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIO 7 P MANENTLV CLOSED SITE <br /> ONE ITEM CJ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SO <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAMEOFOPERATOR <br /> ✓P rn_ /JG fr <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTIONAL) <br /> U h <br /> CITV NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 4S`7 <br /> TOINOIICCATE D CORPORATION E-D INDIVIDUAL 0 PARTNERSHIP LOCALCAG <br /> SENCY DCOUNTY-AGENCY D STATE AGENCY O FEDERAL+IGENCV <br /> TYPE OF BUSINESS ❑ GAS STATION ❑ 2 DISTRIBUTOR DISTRIRESERVATOION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS' NAME(LAST,FIR PHON #WITH C NIGHTS: tiAA/E(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAMEI PCARE OF ADDRESS INFORMATION <br /> cG f <br /> MAILING OR STREET ADDRDDRE N `/ box bIndicate � INDIVIDUAL L-3LOCAL-AGENCY �STATE-AGENCY <br /> 3 Z ✓! .l�( (]CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> ♦ CIT'NAME ! STATE ZIP CODE PHONE#WITH AREA CODE <br /> s f f« <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREET ADDRESS — - ✓ boll to micale Q INDIVIDUAL = LOCAL.AGENCY f]STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 444_-L ] 2- Z <br /> V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> SELF INSURED O 2 GUARANTEE E] 3 INSURANCE d SUREYTBOND <br /> ✓ Lov 0 intlicale <br /> LJ 5 LETTER OF CREDIT D 6 EXEMPTION CJ 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.❑ IN.❑ <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 B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# <br /> 3` I t%3 / / b <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z3 3 8 <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 /> FORMAn2-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORW73A R6 <br /> 0 0 1 <br />