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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 3 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED <br /> SffF- <br /> ONE ITEM E-] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& DDRE S-(MUST BE COMPLETED) <br /> DBA ORF CIL) AM NAME OF OPERATOR <br /> ADDRESS NEA TCROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAM STATE ZIP C E SITE PHONE WITH AREA CODE <br /> v BOX <br /> _ CA <br /> TO INDICATE CI CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNrY.AGENCY D STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RV IF NTDIIAN ON N OF TAFT SITE E.P.A. I.D.#IgPNA 1) <br /> 3 FARM O 4 PROCESSOR O 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) PHONEA WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME . CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Io rxkc la INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> AA -An CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY E�:] FEDERAL-AGENCY <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 /> MAILING OR STREET ADDRESS ✓ box blMcab O INDIVIDUAL O LOCAL-AGENCY L7 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTYAGENCY = FEDERALAGENCY <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 44 - u <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkale I SELFINSURED2 GUARANTEE i7 3 INSURANCE (] A SURETY BONG <br /> O 5 IETTEROFCREDR 6 EXEMPTION 0 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= II.O 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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> T_1 0 <br /> LOCATION COD - PTIONAL CENSUS TRACT# -OP 10 AL o o SUPVISOR-DISTRICTC OE -) TIONAL_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A/C#/HHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM33A-R5 <br />