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. < <br /> (,. STATE OF Ca 1 <br /> STATE WATER RESOURCE.w, ROARD i 70 <br /> UNDERGROUND STORAGE TANK PERMIT A. .i�.:9TION - FORMI A v; <br /> v <br /> ry. <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY 0 3 NEW PERMIT 0 3 RENEWAL PERMIT EVrs CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED_S"i <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY FORMATION&ADDRESS-(M ST BE COMPLETED) <br /> DBAORFA NAME NAMEOFOPERATOR <br /> 60 u c in <br /> KESS NEAREST CROSS STREET PARCEL*(OPTIONAL) <br /> CITY NAME STATE ZIP DOGE SITE PHONE#WITH AREA CODE <br /> CA <br /> OINgC TE C DONATION = INDIVIDUAL PARTNERSHIP = AL-AGENCY =COUNTY STATE-AGENCY FEDERALAGENCY <br /> S,RICTS -- <br /> TYPE OF BUST GAS STAT pq = ✓ IF IAN N OF TANKS AT SITE E.P.A. L D.#(optimal) <br /> RES ATION <br /> = 3 FARM O 4 PROCESSOR = 5 OTHER OR TR TLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) MERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> J e//' - L/(.-36 su ..,-- <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> A7 NAG S R/nG <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bDX bkEkab =INDIVIDUAL = LOCAL-AGENCY =STATE AGENCY <br /> �(J �La' =CORPORATION = PARTNERSHIP =COUNrYAGENCY FEDERAL-AGENCY <br /> CITY NAME // STATE ZIP CODE PHONE#WITH AREA CODE <br /> L!C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boll binOkaN INDIVIDUAL = LOCAL-AGENCY =STATE AGENCY <br /> =CORPORATION = PARTNERSHIP = COUNTY-AGENCY = 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) HQ 4 4 - 0 3 2 <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindkale 1 SELF-INSURED =2 GUARANTEE (= AN <br /> 3 INSURANCE =4 SURETY BOND <br /> =5 LETTER OF CREDIT =6 EXEMPTION = 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I gr II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA IN TED B S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO� I—�UTNTTY# JURISDICTI Go (/ FACILITY# <br /> 131f] <br /> 7 <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVLSOR-DISTRI CODE -OPTIONAL <br /> A 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(3)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS19WCHME OF SITE INFORMATION ONLY. <br /> FORM A(5-91) / FOR0033A 5 <br />