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o.p c� <br /> STATE OF CALIFORNIA + <br /> STATE WATER RESOURCES CONTROL BOARD i �. '• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� n; <br /> COMPLETE THIS FORM FOR EACH FACIL TYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMITS CHANGE OF INFORMATION O 7 PERMANENTLY RE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME // f NAME OF OPEflATO <br /> C N 4G taa f e/ 7 P) OAr7 air <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> $ T\1CIN NAMEml <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> �n C/� S <br /> TOINgCATE El CORPORATION LeMO-DIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY E=l FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR .1IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(aplionap <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAP,112(LAST,FIRST) I PH E#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a it �e Zt�j 599^ 3553 <br /> 1 PI4nNE WITH <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME I— �ai CARE OF ADDRESS INFORMATION <br /> MAILING OR STREED/ ESS box biMaIRUIVIDUAL LOCAL-AGENCY =1 STATE-AGENCY <br /> CORPORATION = PARTNERS14P COUNTY-AGENCY = FEDEMLAGENCY <br /> CITU NAMEc l STATF�., ZIP ?5 3(96 P r�WITH AREA CODE� <br /> ki 1ONE 5553 <br /> III. TANK OWNER INFOR'M'ATION-(MUST BE COMPLETED) C � <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> arae as � <br /> MAILING OR STREET ADDRESS ✓ box HlMkate L2rVDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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]-4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to hdicM SELF-INSURED 2 GUARANTEE 3 INSURANCE (]4 SURETY BOND <br /> 0 5 LETTEROFCREDIT O 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[—] II.®_ III.❑ <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CO/3UNTY# JURISDICTION# �F�ACILfTV1 �AT�'j3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR.DISTRICT CODE -OPRONAL <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 /> FORW33A5 <br /> FORMA(5-91) A <br />