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•°b�,,.,. �o <br /> STATE OF CALIFORNIA +: <br /> STATE WATER RESOURCES CONTROL BOARD � 4 <br /> f, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o; <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY F—] T NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT = 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I NAME OF OPERATOR <br /> Dr, Ij <br /> A013t NEAREST CROSS STREET PARCEL#CFHONAU <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CAI/ BOX <br /> CCJ <br /> TOINDICATE O CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY STATE-AGENCY E71 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS T GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN S AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM = 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: E(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 COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bol iD Ndmb INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> D CORPORATION Q PARTNERSHIP D COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 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 ✓ bot bindbal# INDIVIDUAL O LOCAL-AGENCY [7:1 SrATE-AGENCY <br /> O CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <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 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> boo mdi.lo O 1 SELF-INSURED0 2 GUARANTEE O 3 INSURANCE O 4 SURETY BONG <br /> 0 5 LETrEROFCREDIT EXEMPTION E-199 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.F_� II.0 III. <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY C <br /> COUNTY# JURISDICTION# <br /> � o J <br /> LOCATION DE - TIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FOM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(S91) - � FORW77AS <br />