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ow � <br /> STATE OF CALIFORNIA �O'� <br /> STATE WATER RESOURCES CONTROL BOARD ey <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W aa� <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM a 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTONAU <br /> 19/ e <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> /Yy ca— CA <br /> I/ BOX <br /> TO INOCATE CORPORATIONIVOUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR E--1 RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM I7 4 PROCESSOR L?115 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 /> '641/Loin 4 — <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P ONPf WITH AREA COOP <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0ww"19 0 INDIVIDUAL E::] LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> 5G irle a S L <br /> MAILING OR STREET ADDRESS ✓ boxblWbaW Q INDIVIDUAL E:j LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 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 F4—F-41- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindi 1 SELF-INSURED 2 GUARANTEE = NSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION VOTHER <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.O III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACIILITTYY1 14 s# <br /> m _ (� <br /> LOCATION COD L # -OPTIO OR STRI <br /> THIS PQRMyUSj-BFA000IrPANIED BY AT LEAST T APPLICATION- FORM B,U ANGE OF SITE INFORMATION ONLY. L <br /> FORM A(S91) FOR0033A5 V7 <br /> `pr's �... -✓ l^J <br />