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STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> T UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DGA Oil FYICILITY NAME NAMEOFOPERATOR <br /> ADD NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME USTATE21P CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOINICDCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F71 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TA SITE E.P.A. I.D.#(opdonap <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY Z15NTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) WITH ABEA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA QOnF <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicas Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE 21P 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 ✓ bm b Indicate Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNrRAGEHCY Q 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) HO 4 4 - Z Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binEbaN Q 1 SELFINSURED Q GUARANTEE Q 3 INSURANCE Q 4 SURETYBOND <br /> Q 5 LETTER OF CREDIT LV6 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.❑ II.❑ 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 MONTWDAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY tt LLIJURISDICTION# FACIL"# <br /> iameL93 <br /> LOCATION CO -OPTIONAL CENSUS TRA92_OPypN�L SUPVISOR-DI ICT CA_DE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED FAT LEAST(1)OR MMOORE PERMIT APPLICATION• FORM B,,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A"5 <br />