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STATE OF CALIFORNIA �� s <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A as <br /> COMPLETE THIS FORM FOR EACH FAGft:ffY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ Z INTERIM PERMIT { AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSAOR FACILITY NAME NAME OF OPERATOR .i <br /> ADDRESS NEAREST CROSS STREET PARCELr(OFTIONAU <br /> CITY NAME STATE ZIPCOOS SITE PHONE A WITH AREA COOS <br /> ✓ eoz CA <br /> TOINOICATE CdCORPORATION Q INDNOUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY <br /> DISTRICTS Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2-DISTRIBUTOR/ IF INDIAN 10 OF TANKS AT SITE E.P.A. L D.s(optbaii?) <br /> Q 3 FARM a PROCESSOR 5 OTHER ❑ RESERVATION <br /> OR TRUST LANDS Q <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST( PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �i P Pi' .B�' an �v 9 -� 3� 3S'3 <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PPONP t WITH AREA C <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME p CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES9 ✓✓ bm * Q IHdVOUAL Q LCCk-AGENCY Q STATFACENLY <br /> IJ°'CON'OIiATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL CITY NAME STAT ZIP CODE PHONE A WITH AREA CODE <br /> Id <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> .S <br /> MAILING OR STREET ADDRESS ✓ Oo[NugNAq Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CWKrYAGENCY Q FEDERtLAGENCY <br /> CITY NAME STATE 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) HQ F4-F47- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> RVY <br /> ✓OM billefew I SE 411SURED Q 2 GUARAMEE 0 INSURANCE <br /> Q S LEITER OF CREDIT Q A� eoNo <br /> Q 8 EXEMPTION Q 9➢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 IIL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION X FACILITY A � <br /> 3 q � <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL �SUPISOR-DISTRICT CODE -OPTIONAL <br /> °t' r2 3,4 o 3 d 6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S-91) \ FCA=X$ <br />