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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :� o <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> TOBAR FACILITY# NAME OF OPERATORYtiG PARCELO(OPTKINAL) <br /> ESS NEAREST CROSS STREET <br /> CITY NAME STATE ZIP LADE SITE PHONE i WITH AREA CODE <br /> CA <br /> TO INDIBOXCATE 0 CORPORAT 0 INDIVIDUAL 0 PARTNERSWP 0 DISTRICTS COUNTY-AGENCY STATE-AGENCY 0 FEDERAL#GENLV <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. 1.D.#(WtWal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,F/IIR" T PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> � P N✓KRN JC)�N . PHI 2 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> L h �v <br /> MAILING OR STREET R -7 ��ktN� ✓bUbindc0 Q INDIVIDUAL L-AGENCY ED STATE-AGENCY <br /> r 0 -7 L(O O CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> Sa CA-u C-4 5-6X, Yo -yds 47U.3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ SLt 'k..? 0. 0 Z1- . <br /> MAILING OR STREET ADDRESS• ✓ bAbiml: N O INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> S A OL & -,jr 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 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 L4]4]-1013 2- <br /> V. <br /> V. PETROLEUM UST FINANCIAL SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor blMeale SELEINSURED 0 2 GUARANTEE E] 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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 ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# STE FA /y <br /> LOCATION CODE OPTIONAL (CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 / ? 38� 3a3 Co glalti3 <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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F01003A R6 <br /> 6.01 <br /> L <br />