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STATE OF CALIFORNIA ° <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT EV6 CHANGE OF INFORMATION L_] 7 PERMANEN <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRRESS-(MUST BE COMPLETED) <br /> / WV/1 NAM§r�D f �R �CtrK<nso� <br /> DB FACILITY NAM 1J- K ({/1pN✓ <br /> A D 17 NEAR ST CROSS EET PARCEL#(OPTIONAL) <br /> wI V <br /> CITY NAM STATECA ZIP CODE SITE PHONE•WITH AREA <br /> ✓ POx OgPORATION O INDIVIDUAL PANTNEflSHIP O LOCA4AGENCV COUNTY AGENCY l 1 STATE-AGENCY l� FEOEML-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE,/ IF INDIAN <br /> SERVATION #Of TANKS AT SITE E.P.A. 1.D.A IapfianalJ <br /> 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 5 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE>t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE I WIT14 AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxomum INDIVIDUAL = LOCAL-AGENCY ED STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> 1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ box blMkaN = INDIVIDUAL = LOCAL AGENCY STATE-AGENCY <br /> CORPORATION E—j PARTNERSHIP =COUNTY-AGENCY 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 4 4 - Q D O <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindbau 1 SELF INSURED [:D2 GUARANTEE [7 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT =6 EXEMPTION I=I 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ III.❑ <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 MONTHIDAYIYEAA <br /> LOCAL AGENCY USE ONLY n' ' !1 <br /> COUNTY# L /r-r _. JURISDICTION# FACILITY# <br /> ® ��-+- I 1 1111 <br /> LOCATIONCQpE -OPTIONAL CENSUS TRACT -OPTIONAL O SUPVISOfl'ISTRICT CODE OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM BI LESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A 5 <br /> L� <br /> `d <br />