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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH EkMn.SrrE a <br /> MARK ONLY 7-7 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE 0; INFORMATION 7 PERMANE CLOSED SITE <br /> ONE IT 2 INTERIM PERMIT Q A AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> CU <br /> AOORESS NEAREST CROSS STREET PARCELI(OPTONAU <br /> 7�/ t' s. /V ty7` <br /> CITY NAME STATE ZIP CODE SITE PHONE t WITH AREA CODE <br /> .5—,e CA <br /> To1NaCA%TE CORPORATION O INDIV57WL O PARTNERSHIP [I IO LST-AGENCY EDCOUMY/AGENCY O STATE-AGENCY O W <br /> FEDERALAGE 'Y <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O RE- IF INDL s OF TANKS AT SITE E.P.A. L D.s/Pp1arN11/ <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE DAYS: NAME(UST.FIRST) <br /> c <br /> NIGHTS: NAME(LAST.FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> off c x WITu q=o L�c <br /> It. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME (CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ SwbbdIcm INDIVIDUAL O LOCALAGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY#GENCY Q FEDERALAGENCY <br /> CITY NAME I STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AOORESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ m bIIIXJIA = INDIVIDUAL Q LOCAL-AGENCY STATE.AGENCY <br /> ( CORPORATION _i PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME I STATE I ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OFAUZATION UST STORAGE FEE COUNT NUMBER-Call(916)323.9555 8 questions arise. <br /> TY(TK) HO 4 0 ? (o <br /> V. PETROLEUM US PONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �brQr� I,J^ 1 SELF-INSURED 2 GUARANTEE J 3 MSURANCE 4SURETY BOND <br /> O 5 LETTEROFCREDrT O E EXEMPTION W 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: L O 11.= III.U <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 MONTWDAYMEAR <br /> LOCAL AGENCY USE ONLY <br /> COUPITYN JURISD�ICTION1a FACILITY III Iq«E-A'77y <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT• -OP``T��NAL I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> b 3 I 3J 3 C�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(5-911 FOROMM5 <br />