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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDIle tS <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYNAIAzK �n NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> /© 7� <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> l�9-`r cA �SZZz� <br /> T NDox <br /> CATE O CORPORATION Il INDIVIDUAL (] PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY <br /> DISTRICTS O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional)� Q RESERVATION <br /> u ' FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) L=FA CO <br /> PHONE*WITH AR <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME . CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS_ ✓boa b W&NIM O INDIVIDUAL (] G <br /> LAL-AGENCY STATEAGENCY <br /> /O 7 /o LOLLz-F Q CORPORATION 0 PARTNERSHP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME • �j STATE ACTI- ZIP LADE PHONE#WITH AREA CODE <br /> f� d ��% 9 <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ boa bintlbab C INDIVIDUAL f1 LOCAL-AGENCY STATE-AGENCY <br /> p �. li��L�[,"/� CORPORATION = PARTNERSHP L�j COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMEA, <br /> STATE ZIP PHONE#WITH AREA CODE <br /> h <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L�-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ern binkate F—1 1 SELF-INSURED C 2 GUARANTEE 0 3 INSURANCE E7 0 SURETY BOND <br /> E::] 5 LETTEROFCREDR O 6 EXEMPTION [::�j 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.0 II.Fspe III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /� <br /> L <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ' 7 3 J7 9 <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 /> CORM A 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A R6 <br />