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_. STATE OF CALIFORNIA =� s, <br /> 'o <br /> STATE WATER RESOURCES CONTROL BOARD Wog' n; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE °��•a^"'- <br /> MARK ONLY F-1 I NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO E <br /> ONE REM 0 2 INTERIM PERMIT F7 A AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF I Y,41VE NAME OF OPERATOR <br /> ADDRESS �17 AREST CROSS STREET PMCELe(OPIONAL) <br /> It LP As <br /> CITY NAME STATE ZIP SITE PHONE s WITH AREA CODE <br /> CA 42..t <br /> TORN BOX CORPORATION 0 INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY Q COUNT/-AGENCY' M STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'Hamer of UST Is a public agency.conplele the following:name of Supervisor of division,sermon.or officer which operates the UST <br /> TYPE OF BUSINESS Q i GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.If Icprbvll <br /> RESERVATION <br /> 3 FARM a PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EME ENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAVE: NAME(LAST, IRST) PHONE a WITH AREA CGDE <br /> 7] <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST, IPST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INF RMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFOR TION <br /> MAILING OR STREET ADDRESS ✓ WbW&M Q INDIV AL E:3 LOCAL-AGENCY Q STATE AGENCY <br /> O CORPORATION O PARTNkSHIP O OOUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATIO -(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ IWbmisaa 0INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION =PARTNERSHIP COUNTY AGENCY =FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST RAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions Be.I <br /> TY(TK) HQ M44- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Sa bAtlkw O I SELF-INSURE) O 2 GUARANTEE 3 INSURANCE O c SURETY BOND <br /> O 5 LETTER OF CREDIT 0 B EIEMPRON 9B 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.= IL O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,LS TRUE AND CORRECT <br /> OWNERS NAME(PH INTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTKNN If FACILITYx# -fit <br /> 1AL�-�tl--lJ <br /> LOCATION CODE I OPTIONAL CENSUS TRACTi -OPT/QNAL SUPVISOR-OIST�TCODE -OP NAL <br /> O O.7C s SOYlV1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF STTE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATJQNS <br /> FORM A(3531 /// Fp10WMA7 <br />