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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> n, o <br /> – – _-- COMPLETE FORM fOfl EAC CILRY/SRE � �� <br /> MARK ONLYt-NEW PERMIT 'S D RENEWAL PERMI 5 CHANGE OF INFORMATION ] PERMANEN V CLO$`-SRE <br /> ONE I u 2 INTERIM PERMIT L I d AMENDED PERMIT G $ TEMPORARY SITE CLOSURE <br /> I. F CILITY/SITE INFORMATION&ADORES 1 -(MUST BE COMPLETED) 00 <br /> DBA RFACILITYNAME i AME OF OPERATOR <br /> AD RESS <br /> ;.NEAREST SSSS STREET PARCEL-(OPTIONAU <br /> CITY AME [•/ r <br /> J STATE ZIP SITE PHONE ayVITH AREA CODE <br /> ✓ z <br /> ca 9J K <br /> TOINOCATE Q CORPORATIONINDIVIDUAL Q PARTNERSHW Q LOCAL AGENCY Q COUNTYAGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF aUSINE59 1� I GAS STATION I—', Z OISTFIBUTOR Q ✓ IF MOIAN a OF TANKS AT SITE E.P.A. L 0.a(PWl ) <br /> T) 7 FARM J d PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYSN ME(LAST.FIRS 1 PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> aW 74 el <br /> NIGHT . NAME(LAST, IRST( Il' PHONE a WITH AREA CO NIGHTS: NAME(LAST,FIRST) <br /> l PWITH AREA CM9 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ =mffd tas Q INDIVDUAL Cred5EX-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q P/JRNERSHP Q COUNrYAGENCl Q FEDERALAGEICY <br /> CITY NAMESTATE ZIP CODE PHONE a WITH AREA CQOE <br /> jsnq <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 'r 7j <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Oo,eaMlFw Q NORMAL Q LOCAL-AGENCY Q STATE.AGEMCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEPALAGENCY <br /> CITY NAME STATE 1 ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) NO =44 '1Ej- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ 5o.n� Q I SELF-INSURED Q 2 GUARANTEE Q O INSURANCE Q t SURETY BOND <br /> Q 5 LETTERoFCREDIT IQ S EXEMPTION IQ 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.© IL NIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> i <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAP <br /> --9 <br /> LOCAL AGENCY USE ONLY <br /> Z COUNTY JURISDICTION a FA a <br /> 1 =_ _ <br /> LOCATION CODE OPTIONAL •.CENSUS TRACT a -OPTIONAL I SUPVISOR-DISTRICT CODE -CP TlONAL - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF Srm INFORMATION ONLY. <br /> FORM A 112 9+T FILE THIS FORM W, - 'LOCAL AGENCY IMPLEMENTING THE UNDERGROUND? GE TANK REGULATIONS <br /> �j� FORX33Ae6 <br />