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v STATE OFCAUFORWA o. <br /> STATE WATER RESOURCES CONTROL BOARD 3 p epo p o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r ' o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT E—] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA F CILITY NAME �� NAME OF OPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PMCELA(OPfpNAy <br /> TV �J STATE ZIP CODE SITE PHONE#WIT_AREA CODE <br /> CA <br /> v Box <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O RESERVA <br /> 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a Iopba-Wj <br /> Q TION <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE NI WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA DOW <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bNobdbate INDIVIDUAL 0 MCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 8 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box btrdkaN = INDIVIDUAL (] LOCAL-AGENCY []STATE-AGENCY <br /> Lj CORPORATION Q PARTNERSHIP COUNTY-AGENCY = FEDEtALWENCY <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) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE C PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm bintlkaN 0 1 SELF-INSURED EV 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =B EXEMPTION [-1 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E] 11.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 0zm0L9p1_ JURISDICTION# FACILITY# <br /> CWe ✓Rc�3 o 2 ?�g <br /> LOCATION6OE -OPTIONAL CENSUS TRA gD SUPVI$QR ICT 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) FORMA5 <br />