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^eao n e <br /> STATE OF CALIFORNIA s. <br /> STATE WATER RESOURCES CONTROL OARD s <br /> C UNDERGROUND STORAGE TANK PERMIT PPLICATION - FORM A �� <br /> COMPLETE THIS FORM FORE FACILRYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DS CILITY NAME ��� / ��� NAMEOF OPERATOR <br /> UU5 <br /> ADD7SC �1VYV.W. <br /> NEAREST CROSS STREET PARCEL#(OPrx)NAu <br /> CITY N ���L�1/Z�/�7�/ STATE ZIP cq-' z SITE PHONE*WITH AREA CODE <br /> CA (�/7 <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY D STATE AGENCY � FEDEMLNGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 (SAS STATION 2 DISTRIBUTOR / <br /> IF IND ON #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> Q AT <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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODP <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bind� Q INDIVIDUAL D LOCAL-AGENCY 71 STATE-AGENCY <br /> L__j CORPORATION L�:] PARTNERSHIP COUNTY-AGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX 0Indkale INDIVIDUAL 77:1 LOCAL-AGENCY LLI STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP E71 COUNTY-AGENCY O FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 7474 Q Z O I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMP ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓�i blMkad O I SELF-INSURED O YtUARAKTEE O 3 INSURANCE O 4 SURETY BOND <br /> 5 LETrER OF CREDIT 6 EXEMPTION 0 IN OTHER <br /> 771 <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: I.O it.O 111. <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&S IGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# A4�, CO FACILrTY# <br /> LOCATION COPE -OPTIONAL TRACT#CENSUS -671 O(JAL SUPVISOR T ICT CODE -OPTIONAL <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(541) FORMA 5 <br />