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STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:] T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI90�0TY NAME NAME OF OPERATOR <br /> AA u w <br /> ADDRESS NEAREST ROSS STREET PARCELA(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE♦WITH AREA CODE <br /> CA <br /> TO INDICATE ATE Q CORPORATION Q INDIVIOUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q SrATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORD <br /> RESERVATION <br /> IF INDION A OF TANKS AT SITE E.P.A. I.D.x(optlarap <br /> 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 N WITH AREA CODEDAYS: NAME(LAST,FIRST) <br /> :SN <br /> zo - 9r6s z 6 <br /> NIGHTS: NAME(LAST.FIRST) PHO NE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> a der ,�� <br /> Q INDIVIDUAL <br /> MAILING RSTREET ADDRESS box bi trate Q LOCAL-AGENCY Q STATE-AGENCY <br /> Ao. 130x (3QQ Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> adl+pO j cog I 951/3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> Same- <br /> MAILING OR STREET ADDRESS ✓ box bINkM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ a F41- p D F1 8 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbbtlkale Q 1 SELF-INSUREDQ ARANTEE Q 3INSURANCE Q 4 SURETY SONO <br /> Q s LETTEROFCREDIT r6EXEMPTION Q 99 OTHER <br /> 71 <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.❑ II.❑ 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 TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u JURISDICTION# FACILITY 0 <br /> ® I I 1 / 15 I3Y Rarare z/ <br /> LOCA;;CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> .23•�-O 25--' � <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) FOROO 3A5 <br />