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STATE WATEq RERCES CONTROL BOARD <br /> SOU <br /> ICALIFORNUI <br /> v UNDERGRp(►ND STORAGE TANK PERMIT APPLICATION• FORM A <br /> MARK ONLY COMPLETE THIS FOR EAC A <br /> ONE REM NEW PERMIT10 CILRYiSrTE s. <br /> 3 RENEWAL PER IT <br /> 2 INTERIM PERMIT5 INFORMATION O -Y <br /> I. FACILITY/S � C AMENDED pE CHANGE OF ] PERMANENTLY CLOS -° <br /> E INFORMATION&ADDRESS• TEMPORARY SITE CLOSURE TE <br /> DBA Oil FACILITY E (MUST BE COMPLETED) <br /> ADDRESS ri NAMED OPER OR <br /> CITY NAME GIG NEAREST STREET <br /> / PARCEL Y(OPFpNAU <br /> J STATE ZIP / <br /> 93 6 SITE PHONE• ITH AREA CODE <br /> TO INDICATE CORPORATION INDIVIDUAL <br /> Q PARTNERSHIP AL-AGENCY Q CWNIY#CENCY <br /> TYPE OF BUSINESS DISTRICTS ED STATE-AGENCY Q FEOERALAGEKCY <br /> GAS STATION Q2 DISTRIBUTOR Q RESEIII <br /> RVATDKNJ A OF:TANNS AT SITE E.P.A. L D.•(opriowp <br /> Q 3 f Q APR 5 OTHER <br /> OR TRUSTLANpNs <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT <br /> DAYS N E(LAST.FIRS PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ImPIA <br /> so <br /> NIGHT . NAME(LAST, IFPHONE A WITH AREA CO NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hmbidic� Q INDIVIDUAL AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEOERALAGENCY <br /> CITY NAME STATEZIP CODE_ PHONE A WITH AREA <br /> 7. <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETE ) �7L <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wxvi kMs Q INDIVIDUAL Q LOCIA-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CCIATY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s 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 COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 5mnvdKale Q I SELFINSURED Q 2 GUARANTEE Q 7 INSURANCE Q A BJRETYBDND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION Q 6Y OTHER <br /> Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner x I or II is c <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST(F KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTNIDAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY J IC FA N <br /> t Tom, i <br /> LO(:ATION CODE -OPAONA CENSUS TRACTS -OPTIONAL I I ISUPVISOR-01 IICT CODE OPTIONAL <br /> Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS SREINFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM Wf: THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNO STORAGE TANK REGULATION <br /> FORW]1Afl6 <br />