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STATE OF CALIFORNIA 1W °O: <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC ION • FORM A w � �e <br /> •one'• <br /> COMPLETE THIS FORM FOR EACH CILrrY/S <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT EVS CHANGE OF NFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE REMQ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY ITECLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUSTBE CO LE <br /> PTED) O D 0-/22 <br /> DBA OR FACILITY NAME ft'kAME OF OPERATOR <br /> ADDRESS /J& �� AREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME IS EA ZIP CO �/� / SITE PHONE#WITH AREA CODE <br /> 77 <br /> TAA <br /> v BOX <br /> T NDICATE Q CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPEOF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RE ERVADTION #OF TANKS AT SITE E.P.A. I.D.#(optiorrel) <br /> O 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRS PjV,O_NE i WIT AREA O DAYS: NAME(LAST,FIRST) <br /> III <br /> NIG : NAME(LAST, IR �PHHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIR ST) PHONE#WI <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED 7 7 <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET <br /> /ADDRESS ✓box bindicate Q INDIVIDUAL LOCAL-AGENCY Q STATEAGENCY <br /> 7 J L Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FENRAL#GENCY <br /> CITY NAMESTATE ZIP CODg PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLET D) 9S <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> GLw•C <br /> MAILING OR STREET ADDRESS wxbintlbale Q INDIVIDUAL Q LOCAL#GENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEML#GENCY <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 N- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b ineicab = I SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETrEROFCREDT Q 6 EXEMPTION Q 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: L IL III. <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAVNEAR <br /> LOCAL AGENCY USE ONLY ZDW <br /> COUNTY# JURISDICTION# FACILITY# <br /> )CATION CODE Dpr ONA( ICENSUS TRACT% PTI AL SUPVISOR-DISTRICTCO AL <br /> Z o <br /> HIS 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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br /> FOg50]3AA6 <br /> �i <br />