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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD y vim, .. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE m ' <br /> MARK ONLY Q I NEW PERMIT E:] 3 RENEWAL PERMIT5 CHANGE OF INFORMATION F-17 PERMANENTLY CLOSED.SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT X, <br /> 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACI�LRV[DAME" ' ,7 f .� NAME OF OPERATOR / <br /> ADD 55 `J PI u/�C_//� /-I / NEARES CROSSSTREET `/` PARCEL. (OPTON4LI <br /> K./ <br /> CITY NAME �O ✓ ` STATE ZIP DE SrPH #WITH AREA CODE <br /> JC' �J CA <br /> ✓BOX 0 CORPORATION pQ INDMDUAL PARTNERSHIP 0 LOCAL-AGENCY O CWNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE �� DISTRICTS <br /> If on rol UST III Pilkagmy,CMVMO# blowirg re d$p ruwrof&isbn.seclbnorffne iAopnelss Ole UST <br /> TYPE OF BUSINESS O 1 GAS STATION a 2 DISTRIBUTOR 0 ✓IF INDIAN #OF TANKS AT SITE E P.A. I.0.#(apfional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> 0 OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIR T) PHO E#WITH AR CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> w e aaw .� <br /> NIGHT . AME(LAST,FIRST) I PHONE#WITH AREA ODE NIGHTS NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ( t 11 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbi6ale =1 INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION =PARTNERSHIP D COUMY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE LP 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 ✓ boaMbdbale Q NDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE LP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boxbidbNa O I SEYMSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETYBOND O 5 LETTEROFCREDR Q 6 EXEMPTION O T STATE FUND <br /> �8STATE RIND&CHIEF FOLWCIALOFFICERLETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.a III.a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANKOWNEYSTITLE DATE MONTHlDAY/YEAR <br /> LOCAL AGENCY USE ONLY e-C, D D 0 <br /> COUNTY# JURISDICTION M FACILITY# I <br /> pill Jw N <br /> LOCATION OD -OPTIONAL CENSU CT#- ZONAL SUPVISOR-DISTRICT CODE -OP710NAL --7x�'4 Iv, <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 /> OWNER MUST FILE THIS FORT H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC STORAGE TANK REGULATIONS <br /> FORMA(6.85) p <br />