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•xco A ea <br /> STATE OF CALIFORNIA c�: <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD t�� ,m s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY L] 1 NEW PERMIT O 3 RENEWAL PERMIT E?�5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM C 2 INTERIM PERMIT F1 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE `7 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> CHAOREAQUTY AIAe NAME OF OPERATOR <br /> ADDRESSS / NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> /D <br /> CITY NAME / v STATE ZIP GO SITE PHONE#WITH AREA CODE <br /> CA <br /> TOI/ BOX <br /> INDICATE CORPORATION D INDIVIDUAL D PARTNERSHIP LOCAL-AG <br /> SENCY D COUNrYAGENCY D STATE-AGENCY FEDERAL-AGENCY <br /> DISTRITYPE OF BUSINESS O 1,09eSTATION 0 2 DISTRIBUTOR0 RESERVADIAN #OF TANKS AT SITE E.P.A. I.0.#Inp#anal) <br /> 3 FARM O 4 PROCESSOR D 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) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME-�S7 `Z CARE OF ADDRESS INFORMATION <br /> d. <br /> MAILING OR STREET ADDRESS ✓box 0IdicM D INDIVIDUAL D LOCAL-AGENCY D STATE AGENCY <br /> DJ,5D CORPORATION [=1 PARTNERSHIP D COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CI NAMES ST ZIP CODE <br /> PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) ( 5 <br /> NAMEOFOWNEJ � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0IwIcale D INDIVIDUAL D LOCAL-AGENCY L A STATE AGENCY <br /> Q 7 DCORPORATION D PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME � - STATE ZIP CQDr ' ,`l 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 14F4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bin]e:aN C 1 SELF INSURED CI 2 GUARANTEE 0 3 INSURANCE d SURETY BOND <br /> (]5 LETTEROFCREDIT D 6 EXEMPTION D W 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.E it.O III.0 <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 S SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ..'� 1,i ON CODE -OPTION CENSUS%RACY OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> �1 Z/2 L 1 F y�g� <br /> THI FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE R ION ONLY. <br /> ORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG "10 <br /> FOR0033A-R6 <br />