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� STATE OF CALIFORNIA ^e <br /> STATE WATER RESOURCES CONTROL BOARD _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� �o <br /> COMPLETE THIS FORM FOR EA&FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D OR ACILITYN / / NAME OF OPERATOR <br /> ADD SS r/�V/L//I I AgEST CROSS STR T PMCELN(OPfIONAI) <br /> CI E. STA ZIP CO r 2 SITE PHONE#WITH AREA CODE <br /> CA J2 7 <br /> _v BOX <br /> TOINp TE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCALAGENCY O COUNTY-AGENCY STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> ❑ ❑ 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 /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Mtlkaw 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blWcam O INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION = PARTNERSHIP I-I COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0WicaN E-A I SELF-INSURED GUARANTEE 31NSURANCE E-1 N SURETY BOND <br /> 0 5 LETTER OF CREDIT EV 6 EXEMPTION 0 93 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.❑ II.❑ 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&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO®# � JURISDICTION# FACILTIFY# <br /> LOCATION -OPTIONAL CENSUSTRACTT�-OPT/LLL SUPVIS -DISTRICT CODE -OPTIONAL <br /> LL [�(J / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A HANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) (/\1J FOR0033A5 <br />