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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; - <br /> Y UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C�l��O1�Y,Y <br /> COMPLETE THIS FORM FOR E!WH FACILITY/SITE <br /> MARK ONLY F-1 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED P m 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYN E NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ��/k2 /t� G/7�f,�4 � 0lie. i <br /> CITY NAME STATE ZIP C / ITE PHO E*WITH AREA CODE <br /> :;' CA ' Zr?lJ _ 7MF <br /> .✓ BOX ,,,������,,,(,,(((((-���-��� <br /> TO INDICATE LQt:uRPORATION (]INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> // DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN 4 OF TANKS AT SITE E.P.A. I.D.#(apfimal) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> 0 o OR TRUST LANDS 31 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST( PHONE M WITH AREA CODE-7 AYS: NAME(LAST,FIRST) PHONE A WITH AREA COnF <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COnP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 7/7� CARE OF ADDRESS INFORMATION <br /> AIL�IN7G OR TREET ADDRESS"'' / ✓ bIrAtm D INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP (]COUNTY-AGENCY O FEDEML-MNCY <br /> CITU E TATE ZIP CODE P NE#WITH R <br /> D 70 —tarp = <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNED I CARE OF ADORE Be INFORMATION <br /> - i34 o�f2 <br /> ILING OR TREET ADD RESS ` I/box 10iNb 0 INDIVIDUAL 0 LOCAL-AGENCY =STATE-AGENCY <br /> 7 RPORATON 0 PARTNERSHIP =COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME ATF <br /> DE HON ;F WIT AREA CODE <br /> �ES�D7�/�oiv 487-/92 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 74F4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bw bh&.w I SELFINSURED L--1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION 0 99 OTHER <br /> 71 <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.O 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 /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrTY# <br /> LOCATION CODE -OPTTONA CE�JSUS TRACTt -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL G�' /` Z <br /> 0 Z G <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO ON ONLY <br /> FORM A(5-91) FOR AS <br />