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`W 11/ eeo°a e <br /> STATE OF CALIFORNIA °°+, <br /> STATE WATER RESOURCES CONTROL BOARD ice, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ve <br /> Ort ,..,. <br /> �. C�l��OYY,� D <br /> COMPLETETHIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY C'OSEn ITE <br /> O/ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY NAME / NAME OF OPERATOR <br /> ADDHESS a aT( NEE TCROSSS REET PARCEL#(OFIONAL) <br /> I FMO <br /> CITY AME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> U`' CA <br /> T NqC TE 34FCORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY D STATE AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORRESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(0WimQ <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS NAME(LAST,FIRST) PHONE�D� H&BEACODE DAYS: NAME(LAST,FIRST) <br /> 1 a c Y <br /> NIG NAME(LAST,FIRST) I ODE NIGHTS: NAME(LAST S <br /> S�/YyL eI - PHONE 4 WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> a <br /> MAILING OR STREETA DRESS ✓box IRinOicale D INDIVIDUAL LO LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A <br /> MAILING OR STREET ADDRESS ✓ box 0Mtlkals 0INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> =CORPORATION O PARTNERSHIP O OOUNTY-AGENCY E:) FFDEMLAGENCY <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) HQ F4747- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Dov to mdlcale (� 1 SELF INSURED I�2 UARANTEE E-1 3 INSURANCE <br /> l�X SURETY BOND <br /> D 5 LETTER OF CREDT EXEMPTION O W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.E 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 MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 5 ht FACT <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a 3, o <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 /> FORM A(5 91) FOR0033A-S <br />