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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH CILITYIMTE <br /> MARK ONLY Q t NEW PERMIT S RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMAN LOSEO SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE SIJ <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME Of OPERATOR <br /> N• <br /> AOORE5S I NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODES _ J SITE PHONE x WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY Q PEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR I IQ ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.t(gaNmsl) <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER Oq TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA COOS DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA COQP_ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ buokdkab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNrYAGENCY Q FEMRALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ b9ablWkm 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa 0!Wkab 0 1 SELF-INSURED Q 2 GUARANTEE (Q ]INSURANCE Q A SURETYSONO <br /> 0 5 LETTER OFCREM Q 5 EXEMPTION Q 99 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: 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 /> APPLICANT'S NAME(PRINTEO a SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY Gir <br /> COUNTY n /',,� —v/ JURISDICTION a FACILITY x <br /> vl" 'ovl( &EVI Q 1110 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -WTI L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> D a3 3z <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) / /� / FORON�7Aj5 � <br />