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^ppOVA f <br /> STATE OF CALIFORNIA Wp <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD s`®� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , �a <br /> O.1,s011M�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <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 /> DRAIDRFACILITY NAME NAME FOPERATOR <br /> /3) :0 G1�' ngC <br /> NEAREST CR SSTREET PARCEL#(OPTIONAL) <br /> A <br /> CITY N9ytE 3TATEZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓S CA <br /> I/ Box <br /> TO INDICATE D CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL AGENCY E_ I COUNTYAGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ t GAS STATION O 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apIkOW) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS 5 <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 COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabindkab INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP Q COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY 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 /> MAILING OR STREET ADDRESG ✓ boll blMkai# INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa blMkate Q I SELF-INSURED UARANTEE O 3 INSURANCE O<SURETY BOND <br /> 5 UETTEROFCREDFT EV6 EXEMPTION =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.❑ II.❑ 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT <br /> # JURISDICTION# FACILITY# <br /> LOCATION D -OPTIONAL CENSUSTRACT/,--O6TIONAL SUPVI60R-DISTRICT CODE -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 /> FORM A(5-91) FOR0033A5 ; <br /> �� � � . <br />