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�e w � <br /> STATE OF CALIFORNIA +� °: <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w�`� �° <br /> �. o <br /> u„N,n <br /> COMPLETE THIS FORM FOR EACH FACILRYPSITE <br /> MARK ONLY O T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S1 <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R F CILITY NAME / U 9�IljN F E OPERATOR <br /> ADDR SS //��,, OI/� /�� � NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> �6a103 <br /> CITY PAFF STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> G/' CA <br /> .1 Box <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN <br /> DION #OF TAN K$AT SITE E.P.A. I.D.#(optionall <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#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COQF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Indicate D INDIVIDUAL Q LOCAL-AGENCY O STATE AGENCY <br /> O CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNE R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓OoxblMkate (--1 INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION (] PARTNERSHIP O COUNTY-AGENCY Q FEDERAIAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 Z 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOM P TED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box binWbate 0 1 SELF-INSURED =^ARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> S tETTEROFCREDIT 6 EXEMPTION Q 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 11.0 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PRINTED B S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# �i61' JURISDICTION# FACILrrY# <br /> LOCATION COD T10NAL CENSUS T i� ;OPT11AlAL SUPVISOR-DISTRICT CO -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 /> FORMA(5-91) F7 <br />