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ooa e <br /> ei <br /> STATE OF CALIFORNIA .o <br /> STATE WATER RESOURCES CONTROL BOARD wao'aa� _ y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A •> ,,, <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT S CHANGE OF INFORMATION O 7 PERMANENTLY CLS3 <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT [�] B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NOb1E <br /> NAMEOFOPERATOR <br /> ADDRESS C+C//IL NEAREST CROSS STREET PARCEL#(GPnONAU <br /> CITY NA E STATE ZIP OD SITE PHONE#WITH AREA CODE <br /> CA b <br /> TOv BOX INDICATE D CORPORATION I1 INDIVIDUAL Q PARTNERSHIP �LOCAL-AGENCY �COUNTY-AGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RESERVATTION #OF TANKS AT SITE E.P.A. I.D.#(op#mal) <br /> 0 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY C TACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> *WITH AREA rnDP <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST)) <br /> PHONE*WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ## <br /> MAILING OR STREET ADDRESS `�b]a 1,WkINDIVIDUAL LOCAL-AGENCY OSTATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP O COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE CO LETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ babinEkam INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA DODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT N%BER,Call(916)323-9555 if questions arise. <br /> TY(TK) HOV. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ =WndkaN =I SELF-INSURED 0 2 GUARANT L 3 SURANCE I� d SURETYBOND <br /> =5 LETrEROFCRFD.T 6 EXEMPTION OTHEP <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorllischecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.X I.O 111.❑ <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FA�CIILITTY'y# <br /> v-�--(� <br /> ra <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OP L SUPVISOR-DISTRICT CODE -OPTIONAL <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) FOR0033Ab <br />