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STATE OF CALIFORNIA W+ �'� <br /> STATE WATER RESOURCES CONTROIARD s '. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w��, n a <br /> =< yf,.l o <br /> Cwt�s �, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT^E <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFPCILITYNAM5 NAMEOFOPERATOR <br /> ct� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAMESTATE ZIPCODE �� SITE PHONE#WITH AREA CODE <br /> L CA <br /> TOININ ALo C�i(t TE 11 CORPORATION 0 INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ F INDIAN x OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> RESEIRVATION <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT P RSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) ONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PH <br /> PHONE.WITH AREA rDnF <br /> NIGHTS: NAME(LAST,FIRST) P Ex WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbindbau OINDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOF OWNER CA FADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmb Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORA N O PARTNERSHIP COUNTY-AGENCY Q FEDERAL#GENCY <br /> CITY NAME STATE ZI ODE PHONE x WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)32N9555 if questions arise. <br /> TY(TK) HQ 14R]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bot blMkak f�l SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 0 4 SUREIVBONO <br /> O 5 LEREROFCREDIT =6 ExEMPn0NTIER <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: L❑ II.0 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIO / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• ORM B,UNLESS THIS IS A CHANGE OF SrTE FORMATION ONLY. <br /> AA <br /> FORM A(S81) � _� /� � ^ FO <br />