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STATE OF CALIFORNIA <br /> t� STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y; <br /> COMPLETE THIS FORM FOR EACbWACILrrYISITF <br /> MARK ONLY ❑ 1NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION _] ] PERMANENTLY CLOSEDAT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ? <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J <br /> DBA OR FACILITY NAME Q // NAMEOFOPERATOR <br /> lc ( `2 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CfTV NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> r CA <br /> ✓ eoz <br /> T 14N TE 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY D COUNTYAGENCY <br /> DISTRICTS O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D. <br /> RESERVATION <br /> ❑ 3 FARM 4 PROCESSOR 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 /> L ,e // -Di7 <br /> NIGHTS: AME(LAST,FIRSil PHONE#WITH AREA CODE NIGHTS: NAME(LAS FIRST) <br /> su <br /> I — PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> AlpR r1 la /� /lC.mal <br /> MAILING OR STREET ADDRESS ✓box birdkala 0 INDIVIDUAL (] LOCALAGENCY 11 STATE-AGENCY <br /> I�CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bbdleab INDIVIDUAL Q LOCAL-AGENCY E-1 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY I= 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 F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binLkaN 1 SELF-INSURED [:712 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL[CANT'S NAM E(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# bowf Lai FACT <br /> 9 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTttINAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a3 <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) FORDM3A-5 <br />