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STATE OF CAUFORMA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A%� '// <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �_�( <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IJy7 PERMANENTLY CLO <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE/"- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR ILS NA � NAME OFO RA <br /> V lT/ /7� <br /> ADDR7 NEAREST OIRS'15� PARCEL <br /> A(OPrpNAq <br /> CITY NAT-) STATE ZIP E SITE PHONE#WITH AREA CODE <br /> G CA <br /> BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O k GAS STATION Q 2 DISTRIBUTOR IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(apdanap <br /> I -7RESERVATION - <br /> 0 3 FARM 0 4 PROCESSOR5 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 /> NI TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> %. I PHONE#WITH AREA COOP <br /> IL PROPERTY OWNER INFORMATION- ST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindi b E�:] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPL D) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binUbaW INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COOS PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NU ER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLE ED)—IDENTIFY THE METHODS) USED <br /> ✓ box 0WlCaW O i SELF-INSURED 0 2 GUARANI Q 3 INSURANCE 4 SURETYBONO <br /> O 5 LETTER OF CREDIT =6 EXEMPTIO =99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL O III.O <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIO ODE -OPTIONAL CENSUS TRAC #-OP O L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> A <br /> THIS FORM MUST BE ACCOMPANIED Bnf LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A ^ (!� 1, OK/W `i`iV QeG'A ' \ _ c( /T� A5 <br /> 1�rT(/1 'ALO SI <br />