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�..• STATE OF CALIFORNIA •`��u• < < <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A vo <br /> `/ YI <br /> COMPLETE THIS FORM FOR EACH F CILITY1SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL OLD E <br /> ONE REM ❑ Z INTERIM PERMIT ❑ t AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE /j <br /> I. FACILITYISITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> DSAORFACILITY NAME NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL I(OPTV AU <br /> DD <br /> CITY NAME STATE ZIP CODE_ SITE PHONE•WITH AREA CODE <br /> Box CA J <br /> i01N01CATE 0 CORPORATION =1 INDIVIDUAL PARTNERSHP O LOCAL-AGENCY Q COUNTY-AGENCY <br /> STATE AGENCY FEOEPAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN I A OF TANKS AT SITE I E.P.A. L D.s tgPf nap <br /> RESERVATION <br /> 3 FARM Ci a PROCESSOR THER pq TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> uaYS: N ME(LAST,FIRST) — PHONE A WITH pii ACOOE DAYS: NAME(LAST,FIRST) <br /> Oy i 6 <br /> NIGHT : NAME(LAS ,FIRST) PHONE•WITH AREA CODENIGHTS: NAME(LAST,FIRST) <br /> u <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> NAIL No ORSTREET ADDRESS ✓ O•<a mka• <br /> INDIVIDUAL O LOCAL AGEWCY LJ STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNrY,AGENCY Cj FEDERAL AGENCY <br /> CITY NAME _ STATE ZIP COOED PHONE/WITH <br /> III. TANK OWNER INFORMATION•(MUST COMPLETED) CA-- <br /> J[ / - <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS J mAcinacw OINDVIOUAL a LOCAL-AGENCY O STATE-AGENCY <br /> a CORPORATION Q PARTNERSHIP CWNrY-AGENCY Q FEOEMLAUNCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 d questions arise. <br /> TY(TK) HQ T 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Im b+ O i SELF-INSURED 0 2 GUARANTEE 0 3 WSURANCE a 9 SURETY SONO <br /> M 5 LETTEROFCREDT D A EXEMPnON = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ IIL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPUCANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MCNTWDAY1YEAR p <br /> 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURISDICTION a FACILITY <br /> Ix <br /> �ilNg 11 = 'tz <br /> LOCATION CODE -OPTIONAL (CENSUS TT a •OPTIONAL S VISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BIE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S 91) FOROMA-5 <br />