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STATE OF CAUFORNA '""�`� <br /> STATE WATER RESOURCES CONTROL BOARD s a .y p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A j <br /> COMPLETE THIS FORM FOR EAC CILrTYISITE <br /> MARK ONLY 0 1 NEW PERMIT F--j O RENEWAL PERMIT 5 CHANGE OF INFORMATION F--j 7 ffBH&ff&TLY CLOSED S E <br /> ONE ITEM O 2 INTERIM PERMIT Q A AMENDED PERMIT 5 TEMPORARY SITE CLOSURE`-7 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OSA OR FACILITY NyAE �o � Q u/ NAMEOF YRATOR � <br /> ADDRESSNEAREST CROSS STREET PARCEL/(OPTIONAL) <br /> G� <br /> CITY NAME C 7��� STACA ZIP CODE SITE PHONE/WITH AREA CODE <br /> Box TO INDICATE Q CORPORATWN Q INDIVDUAL Q PARTNERS14P Q LOC DISTRIOTS Y QCOUNTY-AGENCY Q Y Q FEOERLL#GENCY <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTR18UTOfl Q g/ F INDIAN A OF TANKS AT SIT E.P.A. L 0.A IaP mal) <br /> Q O FARM Q A PROCESSORS OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY C ACT PERSON (SE HOARY)-optional <br /> DAYS:NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS:NAME(UST.FIRST) <br /> NIGHTS:NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PWON5 x WITH APPA COQC <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wxmm IIA Q INDNOUAL Q LCCAL.AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSWP Q COUNTY AGENCY Q FFDEM4AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baa amcaM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSMP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cal((916)323-9555 if questions arise. <br /> TY(TK) HO 44 -I'0 a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓5m I,O&M Q I SELF-INSURED 0 2 GUARANTEE Q ]INSURANCE Q I SUREtt BOND <br /> 0 5 LETTEROFCREOT 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.0 IL= IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRWTED A S IGNATURF) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> 0� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION IF FACILITY#CILY <br /> 11� 4ft ;ep/z3K�l IZ <br /> LOCATION CODE -OP igNAI (CENSUS TRACTS •OP_TrE SUPVISOR-DIS ICT CODE -OP rIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FO RM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) /J FCRW71A.$ <br />