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STATE OF CALIFORNIA ° <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB R AGILITY NAMEME / l)� NAMEOFOPERATOR <br /> ' V, / L",/ / )e)Ya NEA T ROSS PMCELIIOPfgNAy <br /> CITVZNJ{AM55E,,, <br /> STATE ZIP CODE � SITE PHONE#WITH AREA CODE <br /> ✓ BOX CA <br /> TOINDCATE CORPORATION INDIVIDUAL = PARTNERSHIP O LOCAL AGENCY COUNTY#GENCY D STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aptknal) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 5 fEyl <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) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot b lWi =1 INDIVIDUAL 0 LOCAL-AMOY Q STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP O COUNTY-AGENCY [] FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot lc iMicaN 7] INDIVIDUAL 0 LOCAL-AGENCY (]STATE AGENCY <br /> CORPORATION (] PARTNERSHIP 0 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) HO 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBEC PLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bot I,Micah (] 1 SELF-INSURED LV 2 GUARANTEE O 3 INSURANCE A SURETY BOND <br /> O 5 LETTEROFCREDIT (]6 EXEMPTION ] W 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.O 11.0 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY* <br /> 3 1 1 1110 <br /> LOCATION COI�G�(� OPTIONAL CENSUfACT# -OPTIOAIAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 7> Q Z <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) FOR0033A-5 <br /> VV y✓ ✓ \3 <br />