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•t60UR f <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> CORI\ORI,\ <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT F_� 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM [::] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI . <br /> NAMEe <br /> NAMEOFOPERATOR <br /> �/ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> o- <br /> CITY NAME7 STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> CABOX <br /> TOINCICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q SrATE-AGENCY Q FEDERALAGENCY <br /> DGTRICTS <br /> TYPE OF BUSINESS STATION 2 DISTRIBUTOR REV IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.#(apRmap <br /> 3 FARM 4 PROCESSOR = 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRS11 <br /> /'PHOO�#WC AREA CODE DAYS: NAME(LAST.FIRST) <br /> __115d P ONE 0 WITH AREA C009 <br /> NIGHTS: NAME(LAST,FIRS ! `/ PHONE#WITH AREA CODES NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bo#bin#k#te Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> f 73T,(/ W- Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITU NAME STATE ZIP CO1:7 `� rONE�#WITH AREA CODE <br /> Ill.. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFO NER ! CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bat ID NiCM Q INDIVNUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> —S 9 /� ��~- Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE ONEIT DE- p <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 /> ✓box bintlka Q I SELFINSURED Q 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT Q 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 SE USED FOP LEGAL NOTIFICATIONS AND BILLING: I.[—] IL 7� 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 <br /> COUNTY If JURISDICTION Al FACILITY# <br /> LOQ6TION GODS -OPTIONAL CENSU TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z 15. 27/ 1 30-0 <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) F0,5 <br /> n <br /> i <br />